LIBRARY OF CONGRESS. 



— - 



Chap..®? Copyright M 



Shel£_iAi>& 



UNITED STATES OF AMERICA, 



THE 



DISEASES OF CHILDREN 



BY THE SAME AUTHORS. 

NOTES ON PHYSIOLOGY FOR THE USE 
OF STUDENTS. By Henry Ashby, M.D., F.R.C.P. 
Sixth Edition. With 141 Illustrations. Fcp. 8vo. price $s. 

HIP DISEASE IN CHILDHOOD. By G. A. 

Wright, B.A., M.B. Oxon., F.R.C.S. Eng. With 48 
Original Woodcuts. 8vo. price 10s. 6d. 



London: LONGMANS, GREEN, & CO. 



THE 



DISEASES OF CHILDREN 



MEDICAL AND SURGICAL 




BY 

HENRY ASHBY, M.D.Lond., F.R.C.P. 

PHYSICIAN TO THE GENERAL HOSPITAL FOR SICK CHILDREN, MANCHESTER 

LECTURER AND EXAMINER IN DISEASES OF CHILDREN IN THE VICTORIA UNIVERSITY 

FORMERLY LECTURER ON PHYSIOLOGY IN THE OWENS COLLEGE 

"jCnD IN THE LIVERPOOL SCHOOL OF MEDICINE 



AND 

G. A. WRIGHT, B.A., M.B.Oxon., F.R.C.S.Eng. 

ASSISTANT SURGEON TO THE MANCHESTER ROYAL INFIRMARY 

AND SURGEON TO THE CHILDREN'S HOSPITAL 

EXAMINER IN SURGERY IN THE UNIVERSITY OF OXFORD 

CORRESPONDING MEMBER OF THE AMERICAN ORTHOPAEDIC ASSOCIATION 



THIRD EDITION 

EDITED FOR AMERICAN STUDENTS 

BY 

WILLIAM PERRY NORTHRUP, A.M., M.D. 

ADJUNCT PROFESSOR DISEASES OF CHILDREN, BELLEVUE HOSPITAL MEDICAL COLLEGE 

ATTENDING PHYSICIAN NEW YORK FOUNDLING, WILLARD PARKER, AND PRESBYTERIAN HOSPITALS 

CONSULTING PHYSICIAN NEW YORK INFANT ASYLUM 

MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS 



NEW YORK 
LONGMANS, GREEN, AND CO. 

LONDON AND BOMBAY 
I896 







Copyright, 1893, by 
LONGMANS, GREEN, AND CO. 

Copyright, 1895, BY 
LONGMANS, GREEN, AND CO. 

All rights reserved 



Press of J. J. Little & Co. 
Astor Place. New York 



THE SURGICAL PART OF THIS BOOK I DEDICATE 
TO MY FATHER 

G. A. WRIGHT 



NOTE TO THE 

SECOND AMERICAN EDITION 



In preparing this edition for the American Reader it has been 
thought best to leave the body of the book intact. The same disease 
differs but little in its course in America and in England ; it is neces- 
sary, therefore, to note only such differences in theory and in treat- 
ment as shall seem to bring the book into accord with present 
American practice. This has been done by means of the Appendix, 
care being taken to refer supplementary matter to its proper connec- 
tion in the main work by page references, and by additions to the 
Index. 

The Formulae (page 811) have been entirely rewritten to conform 
to the United States Pharmacopoeia. 

The supplementary additions to the Surgical portion of the book 
have been made by Dr. T. Halsted Myers, Attending Orthopaedic 
Surgeon to St. Luke's Hospital, New York, whose contributions are 
also embodied in the Appendix. 

The Editor trusts that these additions may still further increase 
the usefulness among American readers of this complete and con- 
densed treatise, which has so quickly passed to its third edition. 

W. P. N. 
New York, i8q6. 



PREFACE 

TO 

THE THIRD EDITION 



In preparing the Third Edition the whole of the work has been 
thoroughly revised, and some of the sections, more especially those 
on Infant Feeding, Anaemia, and Chronic Heart Disease, have been 
almost entirely rewritten. Considerable additions have been made to 
the Surgical part, and mention will be found of the more valuable im- 
provements introduced since the last edition in 1892. The book is 
enlarged by over fifty pages, the formulary has been much expanded, 
and fourteen new woodcuts have been added. 

We must again express our thanks to our colleague Dr. H. R. 
Hutton, and also to our friend Dr. J. S. Bury, for much help and 
kindly criticism. 

HENRY ASHBY. 
G. A. WRIGHT. 

Manchester : September, 1895. 



PREFACE 



TO 



THE FIRST EDITION 



The present work is intended to give to senior students and junior 
medical practitioners a fairly complete, though necessarily condensed, 
account of the various morbid conditions peculiar to, or chiefly found 
during, infancy and childhood. Those diseases which are neither special 
to children nor modified by their occurrence in early life are either 
omitted altogether or only briefly considered. 

The book is written from a practical point of view, and but little 
pathological detail will be found in it. 

The basis of our work is our experience at the General Hospital 
for Sick Children, Manchester, an institution at which some 1,200 
in-patients and some 10,000 out-patients are annually treated. Our 
observations have extended over nearly ten years, and during the whole 
of that time we have been collecting material both at the Children's 
Hospital and at the Royal Infirmary for this purpose. 

The original feature of this book is that it is written conjointly by a 
physician and a surgeon ; it is hoped that it presents, therefore, a fairly 
complete account of disease in children. Though we are well aware 
that the book is not an exhaustive treatise, we think it will be found 
practical, and it is at least based on experience and is not a mere 
compilation. 

The illustrations are almost entirely taken from photographs of 
cases that have been under our own care ; where this is not so, their 
source is acknowledged. 



x Diseases of Children 

We have to tender our cordial thanks to our friends and colleagues, 
both at the Children's Hospital and at the Royal Infirmary, for their 
help. Our thanks are also due to successive generations of house 
surgeons who have kept the records of our cases. 

To our colleague, Dr. Hutton, for allowing us without stint the use 
of his cases, as well as for much help and advice in correcting our 
proofs, our especial thanks are due ; also to Messrs. Southam and 
Collier, our colleagues at the Royal Infirmary and the Children's 
Hospital, for their care and kindness in proof-reading. To Mr. Wilson 
we owe our chapter on Anaesthetics, which is made especially valuable 
by his large experience in the administration of these agents both at the 
Children's Hospital and at the Royal Infirmary. To Drs. Humphrevs 
and Massiah, our former colleagues, we are also indebted for the use 
of their notes of cases. 

We must also acknowledge the help rendered to us by Messrs. Paine 
and Benger in connection with the formulae for medicines and external 
applications given in this work. 

We cannot take leave of our work without further acknowledging 
our indebtedness to the Board of Governors of the Children's Hospital 
for their generous treatment of us, and especially for enabling us to 
publish our annual abstracts of cases treated at the Hospital. We also 
desire to express our appreciation of the value of the work of our sisters 
and nurses in making observations of cases, and in the preparation of 
temperature charts. 

To Messrs. Longman, our publishers, we are much indebted for 
their liberality in allowing us to borrow woodcuts from their published 
works, and for their help in many ways ; we desire also to acknowledge 
the great pains and skill shown by Mr. Pearson in engraving our 
photographs. 

HENRY ASHBY, 

G. A. WRIGHT. 

Manchester : May 1889. 



CONTENTS 



CHAPTER I 

THE PHYSIOLOGY OF INFANCY AND CHILDHOOD 

The periods of life, I ; intra-uterine life, I ; infancy, i ; childhood, 2 ; youth. 2 
respiration, 3 ; changes in the circulation after birth, 4 ; amount of blood ir 
body, 4 ; pulse, 5 ; alimentary canal, 5 ; urine, 6 ; temperature, 7 ; nervous 
system, 7 ; sight, 8 ; hearing, 8 ; taste, 9 ; psychical phenomena, 9 ; sleep, 9 
body weight, 9; length, 10; dentition, 11 ; mortality, 13. 



CHAPTER II 

THE DISEASES INCIDENT TO BIRTH 

Asphyxia neonatorum, 15 ; apoplexia neonatorum, 18 ; cephalhematoma, 20 ; hema- 
toma of the sterno-mastoid, 23; obstetrical paralysis, 24; icterus neonatorum, 
25 ; hemorrhagic diathesis, 27 ; acute fatty degeneration of the newly born, 2S ; 
Winckel's disease, 28 ; gastro-intestinal hemorrhage, 28 ; hemorrhage from the 
genital organs, 29 ; diseases of the navel, 29 ; umbilical polypus, 29 ; ompha- 
litis, 31 ; gangrene cf the navel, 31 ; umbilical arteritis, 32 ; umbilical phlebitis. 
32 ; umbilical hemorrhage, 33 ; tetanus nascentium, 34 : sclerema neonatorum, 
35 ; oedema neonatorum, 36 ; gonorrhceal ophthalmia, 36. 



CHAPTER III 

THE HYGIENE AND DIET OF INFANTS AND CHILDREN 

New-born infants, 37 ; clothing, 38 ; infant feeding, 38 ; wet nurses. 40 : weaning. 
41 ; artificial feeding, 43 ; cow's milk, 43 ; woman's milk. 45 ; cream mixture, 
46; diluted milk, 47 : barley water, &c, 4S ; whey, 48 : peptonisetl milk, 48 : 
Sterilisation, 49 ; condensed milk, 50 ; diied milk foods. 51 ; amount of food. 
52: feeding-bottles, 52; diet from to 12 months, 53; diet from 12 months 
to iS months of age, 54, 



xii Diseases of Children 



CHAPTER IV 

DISEASES OF THE DIGESTIVE SYSTEM 

Examination of the mouth, 55 ; dentition, 55 ; catarrhal stomatitis, 59 ; stomatitis 
erythematosa, 59 ; aphthae, 59 ; parasitic stomatitis, 60 ; ulcerative stomatitis. 
62 ; alveolar abscess, 63 ; cancrum oris, 64 ; acute tonsillitis, 65 ; chronic ton- 
sillitis, 69; tonsillar calculus, 71 ; nasal adenoids, 72; pharyngitis gangrenosa, 
72 ; post-pharyngeal abscess, 73 ; stricture of oesophagus, 74 ; swallowing foreign 
bodies, 75 ; oesophagitis, 76. 



CHAPTER V 

DISEASES OF THE DIGESTIVE SYSTEM {cO/ltiiUied) 

Examination of the abdomen, 77 ; dyspeptic diseases, 78 ; flatulence and colic, 79 ; 
vomiting, 79 ; diarrhoea, 81 ; constipation, 85 ; acute gastric catarrh, 85 ; 
acute gastro-intestinal catarrh— zymotic diarrhoea, 86 ; acute gastro-enteritis, 95 ; 
acute ileo-colitis, 96. 

CHAPTER VI 

DISEASES OF THE DIGESTIVE SYSTEM (continued) 

Chronic gastro-intestinal catarrh— gastro-intestinal atrophy, 98 ; chronic diarrhoea. 
98 ; chronic vomiting, 100 ; diet for indigestion, 106 : dilatation of stomach, 107 ; 
malformations of stomach, 108 ; carcinoma of stomach, 108 ; ulcer of stomach, 
108; thread worms, 109; round worms, no; tapeworms, no; ascites, ill. 



CHAPTER VII 

DISEASES OF THE DIGESTIVE SYSTEM (continued) 

Acute peritonitis, 113; perityphlitis, 117; peritoneal abscesses — intestinal fistula, 
118 ; chronic peritonitis, 121 ; iliac abscess, 125 ; intussusception, 125 ; chronic 
obstruction of the bowels, 134. 

CHAPTER VIII 

DISEASES OF THE DIGESTIVE SYSTEM [continued) 

Tubercular ulceration of the bowels — mesenteric disease, 136 ; congenital obstruction 
of the bowels, 140; imperforate anus, 142; deformities of the umbilicus, 146: 
umbilical hernia, 147 ; inguinal hernia, 147 ; prolapsus recti, 151 ; fistula in 
ano, 154; piles, 154; polypus of the rectum, 155. 



Contents xiii 

CHAPTER IX 

DISEASES OF THE DIGESTIVE SYSTEM (continued) 

Hare-lip, 157 ; cleft palate, 163 ; macrostoma, 166 ; macrochilia, 166 ; microstoma, 
167 ; tongue-tie, 167 ; macroglossia, 167 ; ranula, 168 ; papilloma and condylo- 
mata of the tongue, 168 ; hypertrophy and atrophy of the face, 169 ; branchial 
fistulae, 169. 

CHAPTER X 

DISEASES OF THE LIVER 

Congenital stricture of the bile-ducts, 173 ; catarrhal jaundice, 174 ; acute yellow 
atrophy of the liver, 174 ; alcoholic cirrhosis of the liver, 177 ; syphilitic cir- 
rhosis, 177 ; fatty liver, 178; tuberculosis of the liver, 179 ; hepatic abscess, 180; 
hydatids, 180; tumour of the liver, 180. 

CHAPTER XI 

DISEASES OF THE RESPIRATORY APPARATUS 

The thorax in infancy and childhood, 182 ; infantile respiratory spasm, 183 ; laryn- 
gismus stridulus — child-crowing — spasm of the glottis, 184 ; spasmodic laryn- 
gitis, 188 ; catarrhal laryngitis, 189 ; membranous laryngitis, 192 ; tracheotomy, 
196 ; intubation of the larynx, 206 ; chronic laryngitis, 208 ; papilloma of the 
larynx, 208. 

CHAPTER XII 

DISEASES OF THE RESPIRATORY APPARATUS {continued) 

Bronchitis and catarrh, 210 ; collapse of the lung, 212 ; bronchiectasis and emphysema, 
212; chronic bronchitis and bronchiectasis, 213; broncho-pneumonia, 214; 
secondary pneumonias, 216; chronic broncho-pneumonia, 217; different types 
of pneumonias, 219 ; croupous pneumonia, 225 ; gangrene of lung, 233 ; abscess 
of. the lung, 234 ; pleurisy and empyema, 234 ; asthma, 245 ; diseases of the 
bronchial glands, 246 ; mediastinal abscess, 248 ; lymph-adenoma, 248 ; chronic 
tuberculosis of the lungs, 248 ; fibroid phthisis, 251. 

CHAPTER XIII 

THE SPECIFIC FEVERS 

Feverishness, 254 ; gland fever, 255 : scarlet fever, 257 ; surgical scarlet fever. 258 : 
mild scarlet fever, 261 ; malignant scarlet fever, 201 : complications, 263 ; 
nephritis, 264; measles, 272; mild form, 276: severe form, 270: Rotheln or 
Rubella, 279; diphtheria, 283: pharyngeal form, 2S0 : malignant. jSS ; 



xiv Diseases of Children 

nasal diphtheria, 288 ; laryngeal, 289 ; wound diphtheria, 289 ; complica- 
tions, 289 ; pseudo-diphtheria, 294 ; epidemic influenza, 295 ; enteric fever, 298; 
complications, 302; typhus, 307; varicella, 310; varicella gangrenosa, 312 ; 
vaccinia, 313 ; complications, 315 ; varioloid, 316 ; whooping cough, 317 ; com- 
plications, 319 ; mumps — parotitis, 322 ; malarial fever, 323. 

CHAPTER XIV 

DISPOSES OF THE CIRCULATORY SYSTEM 

Diseases of the heart, 325 ; congenital heart disease, 326 ; patent foramen ovale, 
327 ; patent septum ventriculorum, 329 ; stenosis of the pulmonary and tricuspid 
orifices, 329 ; stenosis of the aorta or mitral valves, 330 ; transposition of the 
aorta and pulmonary artery, 331 ; pericarditis, 331 ; endocarditis, 336 ; chronic 
heart disease, 339 ; acute myocarditis, 343 ; mediastino-pericarditis, 346 ; Ray- 
naud's disease, 347. 

CHAPTER XV 

DISEASES OF THE CIRCULATORY SYSTEM {C0nti?llied) 

Nevus, 349 ; stellate naevus, 349 ; port-wine mark, 349 ; cutaneous nsevus, 350 : 
subcutaneous nsevus, 350 ; mixed nsevus, 350 ; simple nsevi, 350 ; cavernous 
nsevi, 350 ; lymphatic naevi, 356 ; aneurism, 358. 

CHAPTER XVI 

DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS 

Anaemia, 359; anaemia with oedema, 360; simple anaemia, 360; idiopathic anaemia, 
361 ; scurvy, 362 ; enlarged spleen, 363 ; anaemia splenica, 364 ; Hodgkin's 
disease, 366 ; haemophilia, 367 ; purpura simplex, 369 ; peliosis rheumatica, 
371 ; diseases of the retro-peritoneal glands, 371. 

CHAPTER XVII 

TUBERCULOSIS, DIABETES, RHEUMATISM 

Acute miliar}' tuberculosis, 373 ; typhoid form, 373 ; broncho-pneumonic form, 375 ; 
subacute general tuberculosis, 375 ; scrofula and tuberculosis, 377 ; tubercular 
adenitis, 379 ; chronic abscess, 386 ; deep cervical cellulitis — angina Ludovici, 
386; general surgical tuberculosis, 387; diabetes mellitus, 388; polyuria — 
diabetes insipidus, 389 ; rheumatism, 390. 

CHAPTER XVIII 

RICKETS 

Rickets, 393 ; scurvy rickets, 401 ; rickety deformities, 407 ; late rickets, 414 ; osteo- 
tomy, 419 ; lateral curvature of the spine, 421 ; antero-posterior curvature, 426. 



Contents xv 



CHAPTER XIX 

SYPHILIS 
Syphilis, 427 ; acquired syphilis, 427 ; hereditary syphilis, 428. 

CHAPTER XX 

DISEASES OF THE NERVOUS SYSTEM 

Introduction, 438 ; clinical examination, 439 ; cerebral congestion, 439 ; tubercular 
meningitis, 440 ; simple meningitis, 444 ; acute form, 445 ; subacute form, 446 ; 
cerebro-spinal meningitis, 447 ; latent form, 448 ; chronic meningitis, 453 ; 
acute hydrocephalus, 454 ; chronic hydrocephalus, 454 ; hypertrophy of the 
brain, 457 ; atrophy of the brain — sclerosis of the brain, 458 ; tumours of the 
brain, 460 ; tumours of the cerebellum, 462 ; of the pons, 465 ; basal ganglia 
and internal capsule, 465 ; of the cortex, 466 ; of the frontal lobe, 466 ; cerebral 
abscess, 467 ; cerebral haemorrhage, 470 ; post-partum haemorrhage — birth palsy, 
471 ; cerebral haemorrhage occurring after birth — acute cerebral palsy, 473 ; 
medullary haemorrhage, 479 ; embolism, 480 ; thrombosis of the cerebral sinuses 
and veins, 483 ; arteritis — softening, 484, 

CHAPTER XXI 

DISEASES OF THE NERVOUS SYSTEM {continued) 

Chorea, 485 ; hemichorea, 487 ; epilepsy, 497 ; hysteroid fits, 499 ; post-hemiplegic 
epilepsy, 499 ; infantile convulsions — eclampsia, 502 ; tetany, 507 ; nystagmus, 
509 ; head-nodding, 509 ; head-banging, 509; hysteria, 510 ; headaches, 512. 

CHAPTER XXII 

DISEASES OF THE NERVOUS SYSTEM (continued) 

Speech anomalies, 515; deaf-mutism, 516; acquired deaf-mutism, 517; physical 
defects in the mouth, 517 ; mental defect, 518 ; aphasia, 518 ; stammering, 
518; mental affections in childhood, 519; congenital group, 520; develop- 
mental idiocy, 521 ; accidental or acquired, 521 ; cretinoid idiocy, 521 ; back- 
ward children, 523 ; idiocy due to syphilis, 524. 

CHAPTER XXIII 

DISEASES OF THE NERVOUS SYSTEM (continued) 

Spina bifida, 527 ; meningocele, 531 ; spinal meningitis, 533 ; paraplegia, 534 ; 
myelitis, 536 ; Landry's paralysis, 537 ; hereditary ataxic paraplegia 
Friedrich's disease, 538; anterior polio-myelitis— acute atrophic paralysis — 
infantile paralysis, 539; peripheral neuritis, 545 ; pseudo-hypertrophic paralysis, 
545 ; juvenile form of muscle atrophy, 548; muscle atrophy ol the face. 548 ; 
Thomsen's disease, 549. 



xvi Diseases of Children 



CHAPTER XXIV 

DISEASES OF THE GENITOURINARY SYSTEM 

Congenital anomalies of the kidneys, 550 ; Addison's disease — tuberculosis of the 
adrenals, 550 ; hsematuria, 550 ; acute pyelitis, 552 ; lithremia, 552 ; tumours 
of the kidneys, 552 ; tuberculous kidney, 555 ; hydronephrosis, 557 ; renal 
calculus, 557 ; acute nephritis, 558 ; septic nephritis, 559 ; acute parenchyma- 
tous nephritis, 559 ; chronic nephritis, 560. 

CHAPTER XXV 

DISEASES OF THE GENITO-URINARY SYSTEM {continued) 

Stone in the bladder, 562 ; cystitis, 566 ; incontinence of urine, 567 ; retention, 569 ; 
malformations of the genito-urinary organs— extroversion of the bladder, 570 ; 
epispadias, 572 ; hypospadias, 573 ; phimosis, 575 ; balanitis, 576 ; congenital 
paraphimosis, 577 ; masturbation, 577 ; cedema of the scrotum, 578 ; diseases 
of the external genitals in females, 578 ; aphthous vulvitis, 579 ; nomapudendi, 
579 ; irritable mamma, 580 ; abnormalities in the descent of the testicles, 580 ; 
supernumerary testicles, 583 ; congenital displacement or hernia of the ovary, 
584 ; acute orchitis, 584 ; syphilitic testitis, 585 ; tubercular disease, 585 ; 
tumours of the testis, 585 ; hydrocele, 586 ; hydrocele in girls, 587 ; varicocele, 
588 ; ovarian tumours, 588. 

CHAPTER XXVI 

DISEASES OF THE BOXES 

Diseases of the bones, 589 ; acute periostitis, 590 ; chronic periostitis, 598 ; syphilitic 
periostitis, 599 ; acute osteomyelitis, ( 6oi ; acute epiphysitis, 602 ; chronic 
circumscribed osteomyelitis, 604 ; chronic diffuse osteomyelitis, 606 ; strumous 
dactylitis, 609; syphilitic dactylitis, 611 ; leontiasis ossea, 611. 

CHAPTER XXVII 

DISEASES OF THE JOINTS 

Tubercular disease of the shoulder, 616 ; disease of the elbow joint, 616 ; of the 
wrist, 617 ; of the ankle, 618 ; acute synovitis, 619 ; pyaemic joint disease, 620; 
exanthematous synovitis, 620 ; chronic rheumatic arthritis, 620 ; syphilitic 
synovitis, 621 ; acute suppurative arthritis of infants, 622 ; acute tubercular 
synovitis, 624 ; sacro iliac disease, 636 ; disease of the temporo-maxillary 
joint, 637 ; hysterical joints, 638. 

CHAPTER XXVIII 

HIP DISEASE 
Hip disease, 639. 



Contents xvii 

CHAPTER XXIX 

SPINAL DISEASE 
Caries of the spine, 664 ; costo-vertebral disease, 677. 

CHAPTER XXX 

CLUB-FOOT, DEFORMITIES OF LIMBS, ETC. 

Talipes equino-varus, 678 ; T. valgus, 680 ; T. equinus, 680 ; flat-foot, 689 ; wry- 
neck or torticollis, 691 ; diseases of muscles, 693 ; tenosynovitis, 693 ; various 
congenital malformations, 694 ; supernumerary digits, 696 ; club-hand, 697 ; 
web-fingers, 698 ; congenital rigidity of joints and contractions, 699 ; congeni- 
tal dislocations, 700. 

CHAPTER XXXI 

DISEASES OF THE NOSE 

Acute catarrh, 703 ; chronic catarrh, 703 ; nasal polypi, 705 ; malformations, 705 ; 
epistaxis, 706 ; nasal deformity, 706. 

CHAPTER XXXII 

DISEASES OF THE EAR 

Diseases of the external ear, 707 ; affections of the external meatus, 707 ; inflam- 
mation of the middle ear, 708 ; of the labyrinth, 711 ; intracranial abscess, 711. 

CHAPTER XXXIII 

TUMOUR GROWTH IN CHILDHOOD 

Sarcomata, 713 ; neuroma, 714 ; enchondroma, 715 ; exostosis, 716 ; cystic tumours, 
716 ; fatty growths, 719 ; giant foot, 720 ; compound congenital tumours, 721 ; 
congenital sacral tumour. 722; lymphoma, 724; cystic growths of the jaws, 725. 

CHAPTER XXXIV 

DISEASES OF THYROID AND THYMUS 
Acute enlargement of the thyroid, 726 ; goitre, 726 ; thymus. 727. 



xviii Diseases of Children 



CHAPTER XXXV 

DISEASES OF THE SKIN 

Eczema, 729; impetigo, 736 ; . seborrhcea, 737; erythematous eruptions, 737; 
roseola, 738 ; erythema scarlatiniforme. 738 ; chilblains, 73S ; erythema multi- 
forme, 739 ; erythema nodosum, 739 ; urticaria, 739 ; urticaria papulosa, 740 ; 
lichen scrofulosus, 740 ; psoriasis, 740 ; pityriasis rubra, 741 ; miliaria — suda- 
mina, 741 ; miliaria rubra, 741 ; pemphigus, 741 ; dermatitis, 741 ; drug erup- 
tions, 742 ; tinea tonsurans, 742 ; tinea circinata, 743 ; alopecia areata, 745 : 
favus, 745 ; scabies, 745 ; simple onychia, 746 ; onychia maligna, 746 ; lupus, 
746 ; papilloma, 747 ; hairy and pigmented moles, 747. 



CHAPTER XXXVI 

INJURIES, SHOCK, HEMORRHAGE, ETC. 

Injuries to the head, 748 ; traumatic cephalhydrocele, 74S ; fracture of the base of 
the skull, 749 ; injuries of the chest. 749 ; injuries of the abdomen, 749; inju- 
ries of the limbs, 749; greenstick fractures, 750; ununited fractures, 750 ; sepa- 
ration of the epiphyses, 751 ; primary amputations, 759; primary resections, 
759 ; dislocations, 759 ; burns and scalds. 760 ; shock, 761 ; loss of blood, 761 ; 
pain, 761 ; septic diseases, 762. 

CHAPTER XXXVII 

ANAESTHETICS FOR CHILDREN 

Local anaesthesia, 764 ; cocaine, 764 ; nitrous oxide, 764 ; chloroform, 764 ; ether, 
765 ; A. C. E. mixture, 765 ; the choice of an anaesthetic, 765 ; preparation, 
765 ; vomiting, 767 ; anaesthetics in special operations, 768 ; accidents, 770. 

APPENDIX 77i 

FORMULAE . 811 

INDEX 823 



LIST OF ILLUSTRATIONS 



FIG. 
I. 

2. 



Stomach of a newly born infant (natural size) . 
Lower jaw of an infant at birth, showing dental sacs 
Lower jaw of a child about three years of age 
Meningeal hemorrhage in an infant . 
Double cephalhematoma . . . ' 
Section of a cephalhematoma .... 

Section of an ileo-umbilical diverticulum 

Bottle for allowing milk to stand 

Infant's feeding-bottle ...... 

Fungus of thrush ...... 

Deformity of mouth due to cancrum oris 

Vertical section of human tonsil 

Temperature chart of epidemic tonsillitis 

Hour-glass constriction of stomach 

Thread worm ....... 

Eggs of thread worm . . . . 

Ileo-cecal intussusception ..... 

Scheme of lines of union of face 

Double incomplete hare-lip ..... 

Severe double hare-lip ..... 

Diagrams of hare-lip operations .... 

Macrostoma ....... 

Supernumerary auricle in neck .... 

Anatomy of child's trachea .... 

Parker's tracheotomy tube ..... 

O'Dwyer's intubation apparatus. 

O'Dwyer's extractor ...... 

Temperature chart of broncho-pneumonia . 

,, ,, acute fatal broncho-pneumonia 

,, ,, a case of acute, lobar pneumoni 

,, croupous pneumonia 
,, ,, ,, ,, treated u it 

,, ,, pleuro-pneumonia followed by 

34. Deformity of chest due to empyema . 



4- 
5- 
6. 

7. 
8. 

9- 
10. 
11. 
12. 

L3- 

14. 

i5- 
16. 

17- 
18. 
19. 
20. 
21. 
22. 

23- 

24. 

25- 

26. 

27. 
28. 
29. 
o. 



J' 

31. 
32. 

33* 



PAGK 

6 
11 
12 
18 
21 
21 
30 
47 
53 
61 

65 
66 

67 
107 
109 
109 
126 

157 
158 

159 
162 
166 
170 
t 9 8 

JO J 

2 7 
207 

213 
214 
J 10 
228 
J JO 
2j , 
244 



XX 



Diseases of Children 



fii;. 

35- 
56. 
37- 
38. 

39- 

40. 
41. 
42. 
43- 
44- 
45- 
46. 

47- 
48. 
49- 
5o. 
51- 
52. 
S3- 
54- 
55- 
56. 

57- 
58. 

59- 
60. 
61. 

62. 

63- 
64. 
65. 
66. 
67. 
6S. 
69. 
70. 

7i. 

72. 

73- 
74- 
75- 
76. 

77- 
78. 

79- 
80. 
81. 
82, 



Section of cheesy glands at the bifurcation of the traci 
Temperature chart of acute otitis in an infant 
,, ,, erythema nodosum 

, , scarlet fever 
,, mild scarlet fever . 
,, ,, malignant scarlet fever 

,, ,, post-scarlatinal nephritis 

. , . . cases of measles 

,, . , measles with broncho-pneumonia 

. , , , mild enteric fever . 

enteric fever 

,. with peritonitis 
typhus fever . 
,. ,, chicken pox 



Varicella gangrenosa . 
Temperature chart of modified smallpox 
Plan of fcetal circulation 
Stenosis of pulmonary artery 



Temperature chart of acute endocarditis . 

Acute endocarditis of mitral valves 

Mixed nrevus of face ...... 

Xaevus of face ...... 

Orbital nsevus ....... 

Arterio-venous varix ..... 

Nsevus lipomatodes ...... 

Degenerated nsevus of scalp .... 

Lymphatic nrevus of foot ..... 

Miliary tuberculosis of the choroid . 

Tubercular ulceration of the foot 

Tracing of chest-wall in rickets .... 

Enlargement of epiphyses of lower end of radius and u 
Section through enlarged epiphysis in rickets . 
Section through the junction of rib and cartilage in ric 
Transverse section through the shaft of the ulna in rid 
Rickety deformity of the femora 
Attitude showing deformity in rickets 
Figure showing results of osteotomy . 
A rickety dwarf ...... 

Rickety attitude of spine ..... 

Knock -knee ....... 

Attitude producing curvature of tibia 
Bow-leg ....... 

Several rickety deformities .... 

Thomas's splint for genu valgum . 

Lateral curvature of the spine' .... 

Reclining-board for lateral curvature 

Fissures around the mouth in congenital syphilis 



List of Illustrations 



XXI 



83. 

84. 

86. 
87. 
88. 
89. 
90. 
91. 
92. 
93- 
94- 
95- 
96. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
no. 
III. 

112. 

"3- 
114. 

"5. 

116. 

117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 



Congenital syphilis .... 

Destruction of the nose in congenital syphilis 
Diseases of bone in congenital syphilis . 
Syphilitic epiphysitis .... 

Tracing of ' Cheyne-Stokes ' respiration . 
Chronic hydrocephalus .... 



Sclerosis of brain .... 
Atrophy of the left side of the cerebrum 
Transverse section of the cerebrum . 
Spastic paralysis .... 
Results of tenotomy in spastic paralysis 
Section of brain, showing blood-cysts 



Brain, showing effects of old meningeal haemorrhage 
Medulla, showing haemorrhage .... 

Transverse section of medulla, showing haemorrhage 
Section of brain, showing effects of embolism 
Cyst formed in brain as the result of embolism 
Tetany ........ 

Cretin . . . . . 



A case of cured spina bifida, with talipes 
Section through a spina bifida cured by injection 
Spontaneous cure of spina bifida . 
Occipital meningocele ..... 
Frontal meningocele ..... 
Pseudo-hypertrophic paralysis .... 



New growth in the kidney . . . . 

Congenital renal sarcoma . . ■ . 

Result of a plastic operation for extroversion of the bladder 
Undescended testis seen as a swelling in the inguinal canal 
Diagram showing the commoner forms of hydrocele < 
process ........ 

Acute periostitis of the femur ..... 

Overgrowth of the bones of the right leg . 

Syphilitic disease of both tibia.' ..... 

Epiphysitis of the upper end of the right humerus 
Multiple tubercular dactylitis. . . . 

Overgrowth of thumb as the result of tubercular disease 
Results of tubercular dactylitis ..... 

Tubercular disease of the wrist 

Tubercular disease of the ankle joint .... 

Congenital syphilitic synovitis of both wrists 

Showing the results of erasion of knee .... 



Sh< 



>wing the result of premature use of limb after operation 



431 

432 
433 
434 
443 
455 
45 6 
458 
459 
460 

473 
473 
475 
476 

479 
480 
480 
481 
482 
508 
522 
523 
53o 
530 
53i 
532 
532 
546 
547 
553 
555 
572 
581 

5S6 
592 
597 
599 
605 
610 
610 
010 
617 
619 
621 

OJO 

629 
631 



XX11 



Diseases of Children 



FIG. 
I3O. 

131. 

132. 

133- 
134- 
135. 

136. 

i37. 
138. 
139- 
140. 
141. 
142. 

143. 

144. 

145- 

146. 

147. 
148. 
149. 
150. 

151. 
152. 

153- 

i54. 
i55. 
156. 

i57. 

158. 

159- 
160. 
161. 
162. 
163. 
164. 
165. 
166. 
167. 
168. 
169. 
170. 
171. 
172. 

173- 

174. 

175- 

176. 

177- 



Splint for disease of the ankle and tarsus . 
Resection of the tarsus ...... 

Showing the result of excision of the os calcis . 
Diagram showing the parts most frequently affected i 
Disease of head of femur . 
Section of the head of femur, showing disease 
Specimen, showing disease of the acetabulum 
Lordosis in hip disease ...... 

Position of the limb in the second stage of hip disease 
Side view of the same ...... 



Bryant's splint ...... 

Method of applying extension in hip disease 
Thomas's hip splint applied 



tip 



Result of excision of the 

Caries of the spine . . . . . 

Attitude in spinal caries ..... 

Jury-mast for spinal caries ..... 

Patterns of Thomas's splints for spinal disease . 

Caries of the spine treated with Thomas's splint 

Severe talipes equino-varus ... 

Very severe talipes equino-varus . . . 

Little's tin splint . . . 

Artificial muscle applied ..... 

Little's tin talipes shoe ..... 

Acquired talipes ....... 

Artificial muscle for flat-foot . . . . 

Congenital wry-neck ...... 

Artificial muscle for congenital wry-neck . 

Double thumb . . . 

Intra-uterine amputation ..... 

Arrest of development of limb .... 

Club-hand ....... 

Double club-hand ....... 

Genu recurvatum and talipes calcaneus 

Abnormal position in utero, causing genu recurvatum 

Congenital dislocation of both hips . 

Sarcoma of lower jaw and eyeball . 

En chondroma of spine and fingers 

Multiple enchondromata of finger . 

Hygroma of neck with macroglossia 

Congenital serous cyst of back 

Dermoid cyst of orbit 

,, ,, forehead 

,, ., in lachrymal fissure 

Myxo- lipoma of breast . 
Giant foot 
Congenital cystic tumour of groin . 



hip 



disease 



List of Illustrations xxiii 

FIG. PAGE 

178. Congenital sacral tumour .......... 722 

179. Section of congenital sacral tumour ....... 723 

180. Lymphoma of neck ........... 725 

181. Cystic bronchocele .......... 727 

182. Hairy mole of the face and scalp ........ 747 

183. Separation of the upper epiphysis of the right humerus .... 752 

184. Plan of the development of the humerus ....... 753 

185. Separation of trochlear epiphysis of humerus ..... 754 

186. Arrest of growth of the radius ......... 754 

1S7. Separation of lower epiphysis of left femur ...... 755 

188. Dislocation of the patella 760 

189. Short, large calibre tubes ......... 776 

190. Built-up head for granulations 778 

191. New York Orthopaedic Hospital brace for knock-knee and bow-legs . 780 

192. Knight's bow-leg brace .... 780 

193. Boston Children's Hospital's brace for bow-legs ..... 780 

194. The Davis-Taylor long traction hip-splint 788 

195. Bradford-Goldthwaite brace for correcting deformity at the knee . . 789 

196. Taylor's spinal brace with chin cup . . . . . . . . 791 

197. Whitman's flat-foot support ......... 793 

198. Shaffer's flat-foot support .......... 794 

199. ) 

[- Dr. Freeman s pasteurizing apparatus . . . . . . 798 



DISEASES OF CHILDREN 



CHAPTER I 

THE PHYSIOLOGY OF INFANCY AND CHILDHOOD 

The Periods of Early life. — The life of man is naturally divided into 
three great epochs — viz. a period of Growth and Development, of Maturity ', 
.and of Decline. 

The first division includes the periods of early life, when those series of 
operations are in progress by which the ovum or primitive germ is trans- 
formed into the complete organism ; it may be subdivided into Intra-uterine 
Life, Infa?icy, Childhood, Youth, and Adolescence. 

Intra-uterine life. — During this epoch the embryo depends entirely 
upon its parent for all its wants. The maternal blood supplies it with 
material for constructive purposes, carries away its waste products, and 
renders unnecessary the maintenance of an independent temperature. It is 
clearly a time of great importance to the future being, and it is necessary 
that this development should take place under healthy conditions, inasmuch 
as it is physiologically impossible for an unhealthy or weakly mother to supply 
the wants of the embryo, and any failure in the nutritive powers of the mater- 
nal blood is certain to leave its stamp on the future development of the child. 
An infant may come into the world fairly well developed and plump, from 
the presence of more or less stored-up fat, in spite of the weakly state of the 
mother's health, but it is almost certain sooner or later to exhibit tendencies 
to disease in the direction of the stock from whence it springs. Not only 
may the embryo owe a weakly building-up of its tissues to its mother, but it 
may actually share maternal disease. The foetus may suffer from endo- 
carditis originating in a rheumatic state of its parent, and this lesion affecting, 
as it usually does, the right side of the heart, may lead to malformations, 
which are only too likely to cut short its career. From its parents also the 
foetus may receive the virus of syphilis, from which it may sutler during its 
embryonic life or after birth. It may receive an inheritance of tuberculosis 
or epilepsy, or a tendency to gout or rheumatism. During foetal life many 
anomalies may arise from arrested development or an overgrowth in certain 
•directions : cleft palate and hare-lip are instances of the former, and super- 
numerary fingers and nsevoid growths oi the latter. 

Infancy.— The Romans used the word in fans in its widest sense, and 
though, as its derivation implies, it was originally applied to those who could 

B 



2 The Physiology of Infancy and Childhood 

not speak, it came to be employed by them for children of much older years. 
The terms infancy, premiere enfance and Sauglingsfteriode are most usually 
applied to the first seven or eight months of life, the time during which the 
infant is nursed at the breast, and before the eruption of the milk teeth. It 
is, however, used by some writers to include the whole of the first year. 
Within the first week or two of life the infant has often to contend with con- 
ditions which are peculiar to this period, inasmuch as they depend in one 
way or another on the act of birth. It may be born asphyxiated in con- 
sequence of strangulation by the cord or pressure on the head, or various 
injuries producing hematomas may take place ; or there may be septic in- 
fection in connection with the umbilical cord. The change from placental 
alimentation to the digestion of food in the infant's stomach is a time of 
peculiar danger, especially if artificial food is given, and the mortality 
of infants is much greater during the first week of life than at any other 
period. 

During the first few months of infancy, life is not so purely vegetative as 
it is during the intra-uterine period, yet the mental faculties are in abeyance 
and the movements mostly involuntary or reflex. 

One consequence of the undeveloped condition of the higher or inhibitory 
centres is that the reflex centres are less under control than in later years, so 
that disorderly reflex movements in the form of convulsions are liable to take 
place on the slightest provocation. Growth at this period is extremely rapid r 
the weight more than doubling itself during the first six months of life, and a 
great strain is thus thrown on the alimentary system ; the lymphatic and 
blood-forming organs are also exceedingly active. It is not surprising, there- 
fore, that the diseases which are most common and fatal at this period are 
those connected with digestion and absorption. The infant requires much 
rest, and, indeed, divides its time for the most part between feeding and 
sleeping. It is during this period that 'wasting,' 'marasmus,' or 'atrophy' is 
so common, a result of chronic catarrh of the intestinal tract and a con- 
sequent impairment of the digestive organs. 

Childhood. — The eruption of the milk-teeth marks an epoch in early 
life, the term childhood being applied to the period commencing with the 
first dentition and ending with the commencement of the second, at the 
sixth or seventh year. The terms seconde enfance and Kindersalter are used 
in a similar sense. Growth at this period continues to be active, though not 
proceeding at the same rate as during infancy, but disturbances of the ali- 
mentary system are common, and children quickly waste if digestion and 
absorption are interfered with. 

The osseous and muscular systems are developing so that by the end of 
the first year the child can crawl or even walk with help. It is at the com- 
mencement of this period that rickets, a disease so intimately associated 
with indigestion, often makes its appearance. The mental faculties are 
opening out as the brain develops, and the infant begins to recognise its 
friends and call them by name. During the period of dentition nervous 
disturbances are common, and the lesions giving rise to infantile paralysis 
are apt to take place. 

Youth. — The terms youth, jeunesse and Knabensalter&xz generally applied 
to the period commencing at the second dentition and ending at puberty, or 



Youth — Respiration 3 

about the fourteenth year. During this time the milk teeth are replaced by 
the permanent set, the bones become more solid and the muscles better 
developed, while the mental faculties are exceedingly acute and the mind 
readily acquires knowledge. As puberty approaches the voice becomes 
deeper and the sexual organs undergo a marked increase of development. 
During this period, in which scholastic education is carried on, the memory 
is exceedingly retentive, perhaps more so than at any other time. Children 
at this period easily ' outgrow their strength,' the nervous system is readily 
upset, as is evidenced by the frequency of chorea, and the alimentary canal 
is apt to suffer from chronic catarrh. 

Respiration. — During intra-uterine life the respiration of the foetus is 
carried on by means of the placenta. The blood of the foetus — as far as 
oxygen is concerned — is supplied in a far more imperfect manner through 
the maternal blood, than when after birth the oxygen is taken direct from 
the air in the vesicles of the lungs. Inasmuch as the foetus has no inde- 
pendent temperature to maintain, and its life is spent in continuous sleep, 
its tissues require far less oxygen than it does after birth. This condition 
of things induces a tolerance of oxygen starvation, much greater than in 
adults, that frequently stands it in good stead during the act of birth, when 
the placental circulation is perhaps interfered with through pressure on the 
umbilical cord, and pulmonary respiration as yet is not possible. Infants 
are often born in a condition of asphyxia, especially after severe labours, and 
have been known to survive without either placental or pulmonary respira- 
tion for 10 to 15 minutes, and infants may live for many hours, or even days, 
with the greater part of their lungs in an unexpanded state. The same 
tolerance of a venous condition of blood occurs in other newly born animals ; 
thus Brown- Sequard has shown that a newly born mouse will recover after 
10 minutes', and a newly born guinea pig after 12 minutes' immersion in 
water, while an immersion of 3 to 3^ minutes is fatal to the adult animals. 

In the newly born the respirations amount to about 44 per minute ; 
during the early months of life they vary from 35 to 40 per minute ; at the 
end of the first year and commencement of the second they have fallen to 
about 28 ; during the third and fourth years they are about 25 ; by the 
fifteenth year they have fallen to 20 ; in the adult they vary from 16 to 20. 
Infants and children, as might be expected, give off absolutely less carbonic 
acid than do adults, but relatively more. 

The absorption of oxygen is also relatively greater in childhood than in 
adult life ; the oxygen in the exhaled carbonic acid does not represent all 
the inhaled oxygen, the proportion retained being greater in childhood than 
in adult life. 

In the infant and during the first three years of life the type of respira- 
tion is the abdominal, the diaphragm being the chief muscle used in tranquil 
respiration, the abdomen rising and falling, and the ribs moving but little. 
Later the costo-inferior type is present, respiration takes place both by the 
raising of the upper seven ribs by the intercostals, and also by means of the 
diaphragm, the chest expanding and the abdomen moving slightly. 

In girls towards puberty the costo-superior type is present, the upper 
part of the chest moves freely, the lowerpart and the abdomen hardly at all. 

The vital cubic capacity of the lungs is smaller in proportion to their 

1; 2 



4 The Physiology of Infancy and Chi hi hood 

height in children than in adults. This is due in part to the relative small- 
ness of their lungs and to the greater elasticity and flexibility of their chest 
walls. 

According to Schnepf and Wintrich the vital cubic capacity at different 
ages is shown by the following table : 

3 to 4 years . . about 450 c.c. n to 12 years . . about 1,800 c.c. 

5„ 7 ,, • • „ 900 c.c. 13 „ 14 „ • „ 2,200 c.c. 

8 „ 10 „ . . „ 1,300 c.c. In adults (average) „ 3,300 c.c. 

With regard to the amount of carbonic acid given out by children, the 
following account of an experiment made by the late Dr. Angus Smith, of 
Manchester, is of interest. We quote his own words: i Four children, three 
boys of 6, 7, and 8 years respectively, and one girl of 7, were put into the 
lead chamber which was made for similar experiments, and in order to 
observe them more carefully Dr. Ashby sat beside them. They were 
extremely quiet, and the amount of carbonic acid given out was exactly one- 
half of that which experiment had given me in previous years for a healthy 
man of moderate strength. The amount given out by Dr. Ashby was 
estimated in a separate experiment, and subtracted from that given out by 
the children, which was equal in amount to 0*361 of a cubic foot per hour for 
each. 

' The children were then put in by themselves and became very riotous 
and active, causing the carbonic acid to rise up for each to 0-531 of a cubic 
foot. They were then put in again and requested to be very quiet. They 
had a few cards to play with, and talked a great deal, but were bodily pretty 
still, upon which the carbonic acid fell down nearly to the first amount — 
viz. 0*4139 of a cubic foot. 

' We find that talking raised the amount of carbonic acid only 0-0529 of 
a cubic foot, whilst jumping and laughing raised it 0-1687, or about three 
times as much.' 

Changes in the Circulation after Birth. — The cessation of the placental 
circulation, the inflation of the lungs with air, and consequently the increased 
amount of blood passing through the pulmonary artery, lead to a gradual 
shrinking and obliteration of the various fcetal passages — viz. the vessels of 
the cord, the ductus venosus, ductus arteriosus, and foramen ovale. These 
changes commence after the first few respirations have been taken, and 
within a week or ten days these passages are closed. Not infrequently, 
however, one or other of them remains open for a much longer period, this 
being especially true of the foramen ovale. In 62 cases under 2 years of 
age noted by Parrot, it was only completely obliterated in 4 ; and of 52 
cases between 2 and 9 years, in 26 only was it completely closed. 

With regard to the ductus arteriosus, Parrot found that of 187 cases of 
1 month to 3 years, in 46 it was open, in 18 it was partially closed, and in 119 
it was obliterated. The ductus venosus is mostly obliterated within three 
days ; according to Quincke its remaining partially open gives rise to icterus. 

Blood. — During the last few years, many observations have been made 
of the blood of the newly born and also of young infants, with the object of 
determining the differences as regards the number and character of the 
corpuscles as compared with adults. The results of various observers are 



Blood— Alimentary Canal 5 

in some cases at variance, and some care is required in drawing conclusions. 
The results given must not be taken as being universally correct. The 
nucleated red blood corpuscles found during the early months of intra-uterine 
life are only very exceptionally to be seen in the blood of the newly born 
when born at full time. The red corpuscles are more numerous in the 
newly born (5,000,000 to 6,000,000 per cub. mill.) than in the adult, and also 
vary more in size (Hayem). In a few weeks this disparity in numbers dis- 
appears. The quantity of Hb is also greater in the newly born (Leichen- 
stern). The leucocytes are also both relatively and absolutely more 
numerous ; the greater number are of the small mono-nuclear variety 
(lymphocytes). The eosinophile cells are also increased (Kanthack). 

The amount of fibrin-formers appears to be less as coagulation occurs 
less completely. 

The amount of blood in the body is relatively less than in adults, being 
one-nineteenth of the body weight, while in the adult it is one-thirteenth 
(Welcker). 

In older children in health the blood does not appear to materially differ 
from the blood of adults. 

Pulse. — At the end of foetal life the number of cardiac contractions per 
minute is about 132 in boys and 140 in girls ; in the newly born infant it has 
fallen to 130 to 133. According to some observations, the pulse rate falls 
notably immediately after the ligature of the cord, to regain its normal 
number an hour or two later. During the week succeeding birth it varies 
from 120 to 140, crying immediately increasing the number some 10 to 30 
beats. By the second year it has fallen to no, by the fifth to 100, by the 
eighth year to 90, and by the twelfth to 80. 

During sleep the pulse rate is diminished, especially in infants, sometimes 
by as much as 10 or 20 beats. The pulse is more often irregular in infants 
and children than in adults, and this apart from the influence of disease. 

According to Soltmann the inhibitory action of the vagus is less marked 
in newly born animals than in adults. The circulation of the blood in in- 
fants and children is carried on more rapidly than in adults, and conse- 
quently the tissues are supplied with a superabundance of arterial blood. 
The tension in the arteries is comparatively low, on account of the relatively 
large size of the aorta and arterial system generally. 

According to Vierordt a complete circulation takes 

In newly born infants 12 seconds (134 pulse rate) 
At two years . . 15 „ (107 „ 

At fourteen years . i8*6 „ (87 ., > 

In adults. . .22 „ (72 

On account of the proneness of the pulse to be influenced by excitement 
during infancy, it is of less value in diagnosis at this period than in later years. 

Alimentary Canal. — -For the first six to eight weeks of life there is very 
slight secretion of saliva, only sufficient being formed to render the mouth 
moist. In the third and fourth months the secretion is much more free. >o 
that infants about this period begin to dribble ; the amount o( secretion be- 
comes still larger as the period o( dentition approaches. By the third or 
fourth month the saliva contains ptyalin, and readily converts cooked starch 



6 The Physiology of Infancy and ChildJiood 

into maltose. The stomach of the newly born infant is small, its capacity 
being one or two fluid ounces, by the end of the fourth week from three to 
four ounces, at three months about five ounces, and at the end of the first 
year ten ounces. The muscular layers of the stomach and intestines are at 
first only slightly developed, hence the feebleness of the peristaltic action 
and the tendency to the accumulation of gases in both the stomach and 
bowels. The gastric juice has at first but imperfect digestive powers, and 
the stomach is in consequence quickly exhausted ; the peristaltic action of 
the walls of the stomach is often very vigorous, and may give rise to the 
regurgitation of the food swallowed, especially as the cardiac sphincter is 
weaker and more easily gives way in infants than in adults. For the first 
few months the digestive powers of the pancreatic and intestinal juices are 
exceedingly feeble, so that starches and portions of curd of cow's milk will 
pass through the whole of the intestines unchanged. The secretion of bile 
begins at an early period of foetal life, probably about the third month ; the 
bile accumulates in the small intestines and is passed as the meconium during 
the first few days after birth. It forms dark brown or greenish masses, 




Stomach of a Newly Born Infant (natural size). 



viscous and tenacious, and of a feeble acid reaction, and consists of mucus 
holding in suspension fatty matters, epithelial cells, biliary pigments and 
cholesterine, but no bile-acids. Three or four days after birth the meconium 
is succeeded by the golden yellow semi-liquid stools characteristic of the 
healthy infant. This yellow colour is due to the bili-rubin of the bile ; the 
green colour sometimes seen in intestinal catarrh depends upon the oxidation 
of the bili-rubin and formation of bili-verdin. Under normal circumstances 
newly born infants have two or three stools daily. Their character gradually 
changes as the infants get older, becoming more and more like the stools of 
adults. 

Urine. — The newly born infant generally passes water within 24 hours 
of its birth and continues to do so some 10 or 12 times daily, passing about 
1 oz. at a time, or about 10 oz. in 24 hours. The first urine passed is cloudy 
from the presence of uric acid and epithelial cells, and is of specific gravity 
1003-1006 ; later it becomes clear and of a light straw colour. It contains 
more uric acid and less urea (about -5 per cent.) than does that of adults. 

During the whole of childhood the urine is of a paler colour and lower 



Urine — Nervous System y 

specific gravity than during adult life ; smaller quantities are also passed, but 
on account of the difficulty of collecting the total quantity the amounts have 
not been accurately determined. The following figures may be taken as 
approximative : 

Between 2-5 yrs. about 15-25 oz., containing 5-14 grammes of urea (in 24 hrs.) 
5-9 -- -. 2 5-35 -. .- 14-19 

9- J 4 >> -- 35-4o „ „ 19-22 

Adults ,, 50 ,, ,, 30 ,, ,, ,, 

Temperature. — The temperature of an infant at birth taken in the 
rectum is about ioo° F. (3775 C, Roger, Sommer). A few minutes after 
birth it sinks to 97, or in weakly infants still lower ; in the course of a few 
hours it again rises and remains at about 98*8° F. This temperature or a 
fraction of a degree higher— 98-8 99 F. — maybe taken as the normal rectal 
temperature during childhood and youth. For young children, if exact ob- 
servations are required, the rectum is the best place to insert the thermo- 
meter, as it is difficult to keep the infant quiet with a thermometer in its 
axilla. It is important to remember that the rectal temperature exceeds 
that of the axilla by about 7 F. For most clinical observations the fold of 
the groin or the axilla may be taken. What is also of importance is the time 
at which it is taken. According to the careful researches of Finlayson, the 
diurnal range of temperature amounts to about 2 F., the maximum being 
at 5 to 6 P.M. and the minimum in the small hours of the morning ; the range 
of temperature in adults being somewhat less. 

According to Reitz, the lowest temperature is between 4 and 5 A.M., increas- 
ing to 11 A.M., falling to 2 P.M., then rising to its diurnal maximum at 6 P.M. 

The most recent observations upon the temperature of children in health 
were made by the late Dr. O. Sturges. The most interesting of these were 
made upon two sturdy children living in the country, aged respectively 1 year 
and 2 years. The temperatures were taken at various hours from 10 a.m. to 
midnight, the usual range being 97-4 to 98*6. The highest temperature was 
after breakfast, when the children were most lively and eager for play. 

The heat of the body is maintained with greater difficulty during infancy 
than in later life, a result due not only to the relatively larger surface, but 
also to the much greater vascularity of an infant's skin. Infants and children 
are much more liable to suffer from cold extremities than are adults. 

Nervous System. —The closure of the anterior fontanelle takes place to- 
wards the end of the second year in strong and vigorous children ; in immature 
and rickety children it may be delayed till the third year, or it may be later. 

The cubic capacity of the skull in newly born infants is about one-third 
that of adults, viz. 500 c.c. ; by the second year it is about 1,000 c.c, while 
in the adult it is about 1,500 c.c. The brain of a newly born infant forms 
about 14 per cent, of its body weight, while in the adult it is only 2*37 per 
cent. The brain doubles its weight during the first year (if life 14 oz, to 
28 oz.) ; by the seventh year it has reached 38 oz. ; by the fourteenth or 
fifteenth year 42 oz. to 45 oz. ; the average brain weight oi an adult (male) 
being about 50 oz. The cerebellum after birth develops more quickly than 
other parts of the brain, the frontal lobes more slowly till six years o\ age, 
when they develop rapidly. 

If the brain of a newly born infant be examined, it will be noted that its 



8 The Physiology of Infancy and Childhood 

consistence is much less firm than is that of an adult's, and it is much more 
readily injured. If placed on a plate it spreads itself out or moulds itself 
into any shape more readily than an adult's brain. The pia mater is ex- 
ceedingly delicate and very easily dissected off with a pair of forceps. In 
colour the brain is light grey, often yellowish from the presence of bile pig- 
ments ; there is no well-marked difference between the ' grey ' and ' white ' 
substance as in adult brain, and the convolutions are less distinctly marked.. 
The multipolar cells in the grey matter on the surface are ill developed, as 
also is the pyramidal bundle of nerves which connect them with the basal 
ganglia and internal capsule ; on the contrary, the nerve elements of the 
cord and spinal nerves are well developed. 

From the above facts it is clear that while the excito-motor centres in the 
spinal cord and medulla are well developed at birth, the higher centres on 
the surface of the brain are imperfect, and so also are the strands or nerve- 
paths which connect the higher and lower centres. This agrees also with 
the experiments of Soltmann, who has shbwn experimentally that the appli- 
cation of some form of irritation, as the induced current, to the surface of the 
brains of newly born animals does not evoke movements in the face and 
limbs as it does in adults. The actions of infants — sucking — crying — swal- 
lowing — breathing — are reflex, and inasmuch as they are uncontrolled by the 
inhibitory influence of the higher centres, are apt to be disorderly and ex- 
cessive ; as, for instance, in convulsions. The reflex actions displayed by a 
brainless frog are more violent and vigorous than those displayed when the 
brain is intact. The readiness with which the newly born infants become: 
convulsed is one of the most remarkable features in early life. Hereditary 
influences play an important part, infants coming of a neurotic stock being 
much more prone to convulsions from slight exciting causes than others. As 
the higher centres develop, changes come over the mental character of the 
infant, and the reflex actions become more and more under control and 
dominated by the psychical centres. The movements of newly born infants 
are almost entirely reflex, though certain ' spontaneous ' or ' impulsive 3 
movements, such as stretching the limbs, occur. 

Sight. — In the first week after birth the infant apparently cannot distin- 
guish objects, but can light from darkness. According to Preyer's examina- 
tions, the movements of the eyes are not co-ordinated at first. Konigstein,. 
from an examination of 300 newly born infants, states that they were all. 
hypermetropic. The colour of the iris is bluish-grey or green, but one finds 
also shades of light grey and brown. The same investigator has also' 
noted blood extravasations in the retina, which disappear in a few days. 
The pupils are very large in the newly born, and sensitive to light ; in later 
childhood they can endure strong light better than can adults. Of the colours,, 
children learn first to distinguish white from black ; in the second year they 
learn to distinguish other colours, first red and yellow, later green and blue. 

Hearing-. — In the newly born the mucous membrane of the tympanum is 
swollen so that no cavity is present, consequently they are not very sensitive 
to sounds, but shrill and strong sounds make impression, the infants waking 
with cries. In the first months children hear high and sharp sounds better 
than deep. Older children can hear very weak and high sounds which 
make no impression on adults. 



Taste — Body Weight 9 

Taste. — Newly born infants can distinguish sweet, bitter, sour, and salt 
tastes. 

Psychical Phenomena. — In the second month an infant learns to hold 
up its head and make voluntary movements and to distinguish the voice-, of 
its friends. At the 3rd or 4th week it can laugh, and smiles when caressed. 
In the 3rd to 4th month the infant notices its toys or anything it can hold in 
its hands, mostly putting them to its mouth. At 7 to 9 months the child can 
sit up, and 3 or 4 months later makes attempts to walk ; when a year old 
well-developed children can walk a few steps without help. From this time 
the child begins to say a few syllables, such as td-td, dd-dd, be-be, without 
much notion of applying them ; then words are learnt, and by the end of 
the second year most children can string a few words together. 

Sleep. — The newly born infant sleeps all day except when it wakes up 
for food. At a year old the infant sleeps fifteen to sixteen hours ; from 2 to 3 
years, twelve to thirteen hours ; from 4 to 5 years, no sleep in the day> 
from ten to eleven hours at night ; from 12 to 13 years, eight to nine hours. 
Infants sleep lightly and are easily awakened ; at 4 to 5 years of age they 
are generally heavy sleepers. 

Body Weight. — An infant born at full term weighs from 6^ to yh lb.,. 
7 lb. being an average weight. For the first two or three days of life there 
is a loss of 4 oz. to 7 oz., then a regular gain, so that by the 8th or 9th day 
the initial loss has been made good. According to Gregory, the following- 
figures express the average daily loss and gain during the first six davs of 
life: 

1st day . . loss of 139 grammes or nearly 5 oz. 
2nd „ . . „ 64 „ „ 2\ „ 

3rd „ . . gain of 33 „ about 1 „ 

4th „ . . „ 50 „ „ if „ 

5th „ . . „ 50 „ if x 

6th „ . . „ 36 „ 1 1 „ 

That these figures are by no means universally correct is clear from the 
difference in weight noted by different observers ; thus, according to Lewis 
Smith, in 170 infants born in the New York Infant Asylum (89 male and Si 
female), the average weight of the boys was 7 lb. 1 1 oz. and the girls 7 lb. 
4 oz. Fifty of these were wet-nursed, and weighed when one week old, with 
the following result : 

Increase of weight in ..... 32 cases 

Loss . . . . . . . • 13 jj 

Average gain 4-8 oz. 

„ loss . . y^ „ 

Greatest gain . . . . . .12,. 

„ loss 6 „ 

Growth during the first year, more especially during the first six months, 
is extremely rapid, the infant doubling its weight in the first six months and 
trebling it during the first year. Many observations have been made on the 
weights of children during the first year; the following table exhibits the 
monthly gains, being the a\ erage oi nine infants observed by W. Pfeiffer, who 



IO 



The Physiology of Infancy and Childhood 



■were nursed at the breast at first, and later this was supplemented with cow ; 
milk : 



Age. 
ist month 




Mot 


thly gain. Weight at e?id of the months 

07-. lb. 07.. 

131 . . . 8 51 


2nd , 
3rd , 

4th , 
5 th , 
6th , 








30* 

261 
26" 

21 
21 






10 4 

11 15 

13 9i 
H Hi 

16 3* 


7th , 
8th , 








17 
21 






• i7 5 
18 10 


9 th , 
10th , 








23 
20i 






20 1 
■ 21 si 


nth , 








I I 






22 O 


1 2th , 








7 






22 7 



Growth after the end of the first year is slower, so that the weight is not 
again doubled till the end of the sixth year, and doubled again by the end of 
the fourteenth. 

Length. — The average length of a newly born infant is 19 inches ; it has 
doubled its length by the end of the fourth year. 

Much interest and importance is attached to the increase of weight and 
height during infancy and childhood : weekly weighings, especially during 
the early months of life, give very valuable information with regard to diet. 
It must, however, always be borne in mind that increase in weight, especially 
if it be due to an accumulation of fat, does not always indicate strength, or 
that the food being taken is a suitable one. During childhood, undergrowth 
or loss of weight must be looked upon as an indication of danger and as evi- 
dence of malnutrition. On the other hand, overgrowth without a proportionate 
increase in weight should always be taken as indicative of weakness. 

For further information on this subject, the reader is referred to the ' Life 
History Album ' by Francis Galton. 

The following is a proportionate table of height and weight : 



Height 


Weight 
lb. 


Height 


Weight 


Height 


Weight 
lb. 


in. 


in. 


lb. 


in. 


24 


18 


37 


38 


49 


62^ 


25 


l 9h 


38 


40 


50 


65" 


26 


21 


39 


42 


51 


67* 


27 


22^ 


40 


44 


52 


70 


28 


24 


4i 


46 


53 


72* 


29 


25i 


42 


48 


54 


75 


30 


27 


43 


5o 


55 


m 


31 


281 


44 


52 


56 


80 


32 


3o" 


45 


54 


57 


82^ 


33 


31* 


46 


56 


58 


85 


34 


33 


47 


58 


59 


m 


35 


3Ah 


48 


60 


60 


90 


36 


36 











Dentition 



i i 



It is not only of interest, but it is important, to both weigh and measure 
children at frequent intervals. Periods of under or over growth are periods 
of danger, as indicating either malnutrition or an overtaxing of the strength. 
There should also be maintained a close relation of height to weight. 

Dentition. — At birth the jaw contains the dental sacs with the already 
calcified crowns of the temporary teeth. Besides the temporary teeth, there 
is the calcified crown of one of the permanent set, the first molar, which is 
situated immediately behind the last temporary molar. (See fig. 2.) 

During the interval which elapses between birth and their eruption, the 
teeth are undergoing further development ; the sacs become enlarged, so that 
they are readily felt through the gum as rounded swellings, the edges of the 
teeth become sharper, and the fangs are developed. As the fangs elongate, 
the edge of the tooth comes nearer to the surface of the gum, the latter swells 





Fig. 2. — Jaw ot a Child at Birth, showing the Dental Sacs (Quain's ' Anatomy '). a, the left 
half seen from the inner side ; />, the right half seen from the outer side ; the bone has in 
part been removed to expose the dental sacs, b shows the sacs of the temporary set and 
the sac of the first permanent molar behind the posterior molar of the milk set. a shows 
the same, and also the sacs of the permanent incisors and canine. 



and becomes more vascular, the edge of the tooth appears as a line or point 
beneath the membrane, which finally becomes perforated, and the tooth is cut. 

The temporary set appear for the most part in groups in the following 
order. First group — The lower two central incisors appear from the 6th 8th 
month, followed by a pause of from three to six weeks. Second group — The 
four upper incisors are cut at intervals of a week or two, from the 8th loth 
month, followed by an interval of one to three months. Third group The 
lower lateral incisors, the upper and lower front molars appear .it intervals 
from the 12th 14th months, followed by a pause of two to three month-. 
Fourth group — The canines appear, the upper ones usually being first, from 
the 18th 20th month. Fitth group The posterior molars mostly appear at 
the age of 2 2 \ years. 

The milk set, when complete, remain unchanged for several years, though 



12 



The Physiology of Infancy and Childhood 



the permanent set are gradually becoming developed in their sacs, ready to 
replace the earlier set. 

The following formula exhibits the relation between the temporary and 
permanent set : 

mo. ca. in. in. ca. mo. 
(Upper 2 i 2 j 2 i 2 =io) 

Temporary set -j \t.o 

1 Lower i I 2 ! 2 I i = io) 



mo. bi. ca. in. in. ca. bi. mo. 



Permanent set 



Upper 



Lower 



3 = 16 



At six years of age there are a greater number of teeth in the jaws than 
at any age, there being the milk set and all the permanent set except the 
wisdom teeth. 

It is to be particularly noted that during this period a marked increase 
takes place in the length of the jaw to provide room for the three molars of 




Fig. 3. — Lower Jaw of a Child of about three years, showing the relation of the temporary 
and permanent teeth. The milk teeth of the right side and incisors of the left are shown, 
and also the sacs of the permanent set, except the wisdom tooth, which is not yet formed. 
The large sac near the ramus of the jaw is that of the first permanent molar, and above 
and behind it is the rudiment of the second molar. (Quain's 'Anatomy.') 

the permanent set, which make their appearance posteriorly to the milk set ; 
the bicuspids replace the temporary molars (see fig. 3). 

While the above account represents the state of things which obtains 
under normal conditions, yet important deviations both as to the time of the 
appearance of the teeth through the gum and the condition of the teeth 
themselves frequently take place as the result of disease or enfeebled nutri- 
tion. It is well known that rickets is the most common cause of delayed 
dentition, and not only are the teeth cut later than usual, but the defective 
nutrition which exists in this state frequently interferes with the develop- 
ment of the teeth ; they may in consequence be dwarfed or provided with a 
thin or partially deficient layer of enamel, so that they quickly become carious 
after being cut. 

The jaw of the infant at birth contains the calcified crowns of all the milk 



Dentition — Mortality in Infancy and Childhood 13 

teeth and also the calcified crown of one of the permanent set, namely, the 
first or 'six-year-old' molar, which commences to calcify during the sixth 
month of intra-uterine life. The calcification of the permanent incisors 
commences when the infant is about a month old, the canines at 3 or 4 
months of age and the bicuspids later, in the first or second year. The 
crown of the second permanent molar begins to calcify during the fourth 
•or fifth year, but the wisdom tooth not till about puberty. 

It is plain, therefore, that any illness occurring during the first year, such 
as syphilis, can only affect the calcification of the incisors, canines, and 
possibly the bicuspids. (See Second Dentition, p. 58.) 

The permanent teeth are cut in the following order : 

Molar, first ..... 6 years of age 

Incisors, central .... 7 „ „ 

„ lateral .... 8 ,, ,, 

Bicuspid, anterior .... 9 „ ,, 

„ posterior . . . . 10 ,, „ 

Canines . . . . . .11-12 ,, ,, 

Molars, second 12-13 „ „ 

„ third 17-25 

Mortality in Infancy and Childhood. — In this country, out of every 
1,000 children born, on an average 149 die before the end of their first year 
of life and 263 before the age of 5 years. During the next five years, from 
5 to 10 years of age, 35 die, and 18 more between the ages of 10 and 15 
years. So that out of the original 1,000, 684 will be alive on their fifteenth 
birthday and 316 will be dead. From these figures it is clear that the 
mortality is the greatest during the first year, and that it rapidly declines as 
childhood advances. Indeed, the mortality is the greatest during the first 
day and succeeding days after birth ; thus Korosi, in analysing the ages of 
infants at death, found, out of 26,623 infants born in Pesth during the 
years 1874 and 1875, tnat out °f every 1,000 born, 13 died within 24 hours ; 
57 on the second day ; 34*2 during the first week ; 26*3 during the second 
week ; and 92 during the first month. 

It appears that infant mortality is slowly decreasing in this country, 
though at a much slower rate than adult mortality. Thus in England and 
Wales the mortality during the decades 1851-60 and 1861-70 was equal to 
154 per 1,000. In the years 1871 80 it declined to 149, while in 1881-90 it 
was 142. 

The mortality of infants differs enormously, and is dependent upon the 
amount of care which is taken in their feeding, and the way in which they 
are looked after, as well as upon their parentage. Roughly speaking, it may 
be said that among the rural population of ('.teat Britain, and among the well- 
to-do dwellers of suburban districts, the annual infant mortality amounts to 
100 per 1,000, 900 out of every 1,000 children born being alive at the end o\ 
the first year. This is the average infantile death rate of Norway, which is 
the lowest of any European country, and, indeed, probably in the world. 

In a large city, such as Manchester or Liverpool, the annual death rate 
among infants under a year is 200 per 1,000 births, or, in other words, one- 
fifth of those born never reach the end of their first year. In the worst and 



14 The Physiology of Infancy and Childhood 

most crowded districts there is little doubt that the mortality is at least 300 
per 1,000, one-third of those born never living to become a year old. A still 
higher death rate prevails among the unfortunate class of illegitimate chil- 
dren ; the mortality among these amounts at times in some districts of our 
large cities to 500 per 1,000, not more than half living to be a year old. In- 
deed, the mortality has in some districts risen, as in Salford, to 710 per 1,000. x 

In London the rate of infant mortality is about the same as that of the 
country generally, namely, 150 per 1,000. The mortality is the same in Paris 
as in London, while in most Continental cities it is higher. In Munich (1884- 
1889) it averaged 324 per 1,000 ; in Berlin, 268 per 1,000 ; in Russia, 266 ; 
and in Austria, 255 (Rahts). 

As one would naturally expect, child mortality also differs greatly under 
different circumstances ; thus we find in the healthy parts of England the 
annual mortality of children under five years of age is not more than 50 per 
1,000 (living at that age), that is, out of every 20 children (under five years 
of age) only one will die during the year ; whilst in the worst districts 100 or 
even no per 1,000 perish annually. 

Child mortality is also slowly decreasing in this country. During the 
ten years 1861-70, the mean annual death rate of children under five years 
of age was equal to 68*6 per 1,000. During 1871-80 it fell to 63-5 per 1,000 ; 
while in 1881-90 it fell to 56*8 per 1,000. This, however, is just twice the 
mortality given by Ansell's tables, which are based on the experience ot 
child life among the upper classes, namely, 28*2. 

Of the causes of death in these cases, it may be taken for granted that 
diseases of the digestive system play a most important role ; but statistics 
are more or less untrustworthy, as the causes of death which appear on death 
certificates are often not to be relied upon for purposes of classification. 
Analysing the causes of death from 2,000 cases of infants under two years 
of age, who died while under the care of the medical officers of our own 
Children's Dispensary, we found that of the fatal cases those connected with 
the digestive system head the list, forming 35 per cent, of the total number. 
Bronchitis and its allies caused death in 21 per cent, of the cases ; whooping 
cough in 12 per cent. ; congenital syphilis in 10 per cent. ; and measles in 
9 per cent. 

Among the less frequent causes of death we find tuberculosis, meningitis, 
diphtheria, and various malformations. We must not forget to mention that 
premature birth accounts for some deaths that do not figure in our list, and 
those unfortunately too common cases which are returned as ' found dead 
in bed.' 

Infant mortality should not be calculated, as is sometimes done, by com- 
paring infant deaths with deaths at all ages, or with the number of persons 
living, inasmuch as in a given population there may be many or few children 
or few old people, but it should be calculated on the infant population, or 
the number of children living at that age. Thus the number of deaths in 
infants under a year old should be compared with the number of infants 
living at the time, which is usually calculated as the mean of the births 
in that and the preceding year. In the same way the mortality of children 
under five years is calculated by comparing the deaths in the year with the 
number of children living under five years of age. 

1 See Dr. John Tatham's Health Reports for Salford. 



i5 



CHAPTER II 

THE DISEASES INCIDENT TO BIRTH 

There are certain lesions which can occur only once in a lifetime, inasmuch 
as they owe their origin to the act of birth, or to those important changes 
which occur in the life conditions of the infant when it exchanges the quiet 
dependence of intra-uterine life for the greater activity of an independent 
existence. Though many of these morbid conditions differ from one another 
in various ways, yet they are so intimately associated in their pathology and 
etiology that it is most convenient to discuss them together, rather than to 
relegate them, as is often done, to their respective places in the ordinary 
classification of disease. The act of birth brings its own special dangers to 
the infant as well as to the mother, and it is hardly surprising to find that many 
perish on the threshold of life, and that the mortality during the first few 
days after birth is greater than that of any other period. It must also be 
borne in mind that parturition is not only responsible for many infant deaths, 
but for damage done to the nervous centres by pressure or haemorrhage, 
which may be irreparable, and if the infant lives it is paralysed for life or a 
hopeless imbecile. These diseases which are connected with parturition are 
also of much interest and importance, in that many of them are eminently 
preventible, and are often the result of the ignorance of the friends or neigh- 
bours, who, in the absence of a medical practitioner or trained nurse, preside 
in the lying-in room, or may possibly be the result of ' meddlesome midwifery.' 
However this may be, many a life is lost and various morbid conditions arise 
for want of assistance during the later stages of labour, or for the want of 
care and cleanliness, or from exposure to contagion during the first few days 
which succeed birth. We will first consider the effects of asphyxia, so 
common in newly born infants. 

Asphyxia Neonatorum. — It is hardly to be expected that the transition 
from placental to pulmonary respiration should be accomplished without 
some risk of the cessation of the one before the commencement of the other. 
Fortunately for the infant, as we have already remarked, its nervous centres 
and tissues generally are far more tolerant of a venous condition of blood 
than they arc in after life, for during intra-uterine life the aeration of the 
blood is far less perfectly performed by the placenta than it is afterwards by 
the lungs ; and, moreover, there is a mixture of the placental blood with the 
venous blood of the inferior vena cava before it is distributed to the body. 
(a) The infant may die from this cause before birth, or it may be born 
asphyxiated ;' (b) asphyxia may supervene after birth through failure of 
the pulmonary respiration. 



1 6 The Diseases Incident to Birth 

(a) Asphyxia before birth is caused by the death or faintness of the 
mother, detachment of or interference with the placental circulation, or 
compression of the cord. Asphyxia of the foetus may be suspected if the 
foetal heart becomes faint, the pulsation of the cord ceases or is weak, or if 
meconium is passed. In infants born asphyxiated the symptoms vary ac- 
cording to the degree of asphyxia present ; when slight, the lips are of a 
bluish tint, the skin dusky, the conjunctivae injected, the limbs are motion- 
less, but the muscular tonus is present, the heart's action is slow and mostly 
visible, the movements of respiration are separated by long intervals, or no 
attempts are made unless some strong reflex irritation is applied. In the 
deeper stages of asphyxia the face and lips are pallid, the extremities blue, 
the muscles of the limbs and neck have lost their tonus, no attempts are 
made at respiratory movements, or only a few inspiratory efforts accom- 
panied by indrawing of the ribs and epigastrium, but without any effect in 
expanding the lungs. 

(b) Asphyxia may be due to causes which operate after birth. In rare 
cases a haemorrhage has taken place during birth into the 4th ventricle 
(Horrocks), or into the substance of the medulla, and thus the respiratory 
centres are paralysed. In others, mucus or liquor amnii has been sucked into 
the air passages during the act of birth, or a haemorrhage may have taken 
place into the lungs through pressure during birth (Spencer). Among the rare 
causes, asphyxia may be due to an imperfect development of the diaphragm, 
double pleuritic effusion, syphilitic infiltration of the lungs, and pressure on 
the trachea from enlarged glands. The commonest cause, however, is 
weakness or immaturity on the part of the infant, its ribs being wanting in 
rigidity and its inspiratory forces feeble, so that it fails to draw in air with 
sufficient power to inflate the lungs, and the latter remain to the greater 
part of their extent in the foetal or unexpanded state, a condition to which 
the term of 'atelectasis ' is applied. Those infants who have some complete 
physical obstruction to the entrance of air into the lungs necessarily only 
survive their birth a few minutes ; either no attempt at respiration is made or 
inspiratory efforts are accompanied by recession of the chest walls, without 
any air entering the chest. Premature or weakly infants may survive for 
many hours or even days with a large portion of their lungs in an unexpanded 
state. They are extremely feeble, their cry is weak and whimpering, their 
lips and limbs are dusky blue, and their temperature below normal. Their 
respiratory movements are confined to slight contractions of the diaphragm, 
sometimes accompanied by indrawing of the walls of the chest ; they have 
hardly strength to suck, and are in a drowsy or semi-comatose condition. 
They frequently suffer from local twitchings, less often general convulsions. 
If they live over forty-eight hours they become jaundiced and the limbs 
cedematous. An examination of the bodies of such infants reveals the 
usual signs of death from asphyxia : the blood is dark and fluid ; the right 
heart and veins distended ; the sinuses and membranes of the brain con- 
gested, and a meningeal haemorrhage may be present. The lungs will be 
found in a condition of atelectasis or pulmonary apoplexy. In a case which 
we recently examined in which the infant died six hours after birth, both 
lungs sank in water, were solid everywhere except at the anterior edges, 
where there were clusters of air-containing lobules and also similar expanded 



Asphyxia Neonatorum 17 

vesicles of a light red colour, scattered over the surfaces of the upper lobe. 
The cut sections displayed purple solid lung without a trace of expanded 
lobules, a condition due probably to a pulmonary apoplexy occurring during 
birth. In another case, where the infant lived three days, the lungs and 
. heart together just floated in water, but the lungs everywhere had a solid 
feel, crepitating very slightly ; the surfaces of both lungs were covered with 
distended lobules, while the central parts were solid. As a rule, the upper 
lobes are more often expanded than the bases, and the anterior and inferior 
edges and surfaces more than the central parts. Care mast be taken not to 
confound atelectasis of the lung with pneumonic consolidation ; the latter 
condition is rare in the newly born. 

Treatment. — 1. Remove any mucus or fluid from the fauces and air- 
passages bymeans of the finger or by suction with a soft india-rubber catheter. 
Inverting the body may be useful. 

2. Attempt to excite respiration by some form of irritation applied to the 
skin. Fanning the face or directing a current of air by means of a pair of 
bellows is often of use. This may also be effectually done by placing the 
infant in warm water (ioo° F.), and then dashing cold water over it bymeans 
of a sponge or the hand, or by slapping it with the wetted corner of a towel, 
or, if the Faradic current is at hand, a feeble current may be applied to the 
diaphragm and other inspiratory muscles. 

3. If these methods fail, no time should be lost in directly inflating the 
lungs by a soft catheter passed into the larynx or by Richardson's bellows, 
or by practising artificial respiration by Sylvester's or Schultz's method, 
which is to be continued as long as the cardiac sounds can be heard. 

Active treatment will less often be required in those cases of asphyxia 
supervening after birth from non-expansion of the lungs. Gentle measures 
may be undertaken to excite more active respiratory effects, and to combat 
the somnolence by means of hot and cold water, or by the application from 
time to time of stimulating liniments to the chest. Such infants, however, 
but feebly respond to our efforts, and over-treatment in this direction may 
easily do more harm than good ; our efforts will mainly have to be directed 
to placing the infant under the most favourable conditions for gaining strength 
and gradually bringing about expansion of the lungs. One of the most im- 
portant indications is to maintain its heat. As soon as possible it should be 
surrounded by cotton wool and placed before the fire ; if too feeble to take 
the breast, milk should be drawn from the breast and given the infant by a 
spoon or small feeding bottle. It may even be necessary to feed it by pass- 
ing a No. 12 or No. 14 soft india-rubber catheter (Jacquess patent) into the 
stomach, and thus introducing, by means of a syringe or funnel, half an ounce 
of milk; the catheter must be quickly withdrawn to prevent reflux ot~ the 
fluid. In the care and nurture of these weakly infants various means have 
been adopted ; for instance, placing them in cradles or cots in small cham- 
bers where the temperature is maintained by artificial means. The bos'. 
known of these is the ' Couveuse ' o\~ Auvard, which consists o\ a box. in which 
the basket containing the infant is placed, and maintained at a temperature 
of ioo° Fahr. by means o( a reservoir o\ warm water heated by a special 
arrangement ; a i;lass lid covers in the box. ami ventilation is secured by a 
current of air which has passed over the warm water reservoir. 



1 8 The Diseases Incident to Birth 

Apoplexia Neonatorum. — Cerebral haemorrhage occurring in early life- 
is hardly ever the result of a ruptured artery, but is almost invariably caused 
by a venous congestion, and takes place from the capillary vessels of the pia 
mater or choroid plexuses. The arteries of the young are not liable to suffer 
from atheroma, but retain their elasticity, and, moreover, are not likely to have 
to submit to any unusual strain from an hypertrophied heart. On the other 
hand, the pia mater in early infancy is exceedingly delicate, and its capillaries 
fragile, as can be readily demonstrated by noticing how easily it is stripped 
from the brain by means of dissecting forceps, and how loose is its connection 
with the soft brain substance beneath it. Further, we have already alluded 
to the fact that the cerebral sinuses and veins become distended with blood 
in asphyxia from various causes— a rupture of the capillary vessels of the 







Fig. 4. — Meningeal Haemorrhage in an Infant ; death on the twenty-second day. 
(After McNutt.) 

pia mater takes place, and blood is effused into the sub-arachnoid space. 
This effusion, in consequence of the loose connection of the pia with the 
brain, may extend over a large surface, or burst into the sub-dural space. 
The blood clot may compress or lacerate the brain substance, and if the 
infant lives for a few days it may be followed by softening. The haemorrhage 
may take place during birth, from compression of the umbilical cord, producing 
asphyxia, and is consequently especially common in breech presentations ; 
or it may result from pressure on the head by the uterus or the blades of the 
forceps (Spencer). We must bear in mind that the pia mater is not only 
very delicate and its capillaries easily ruptured if they are over-distended, 
but also that a stasis is very apt to occur in the superficial veins on account 
of their peculiar connections. Gowers has laid stress on the fact that here 
ascending arteries pass into ascending veins, and, moreover, these surface 



Apoplexia Neonatorum 19 

veins empty themselves into the superior longitudinal sinus in a forward 
direction and consequently against the blood current. Thus the Sylvian 
vein commences in the fissure of that name and courses upwards to empty 
itself into the superior longitudinal sinus, receiving the small veins from the 
motor area en roicte. Near its commencement the Sylvian vein has con- 
nections with the superior petrosal sinus (Trolard) and also with the basilar 
vein. 

Spencer l comes to the conclusion, as the result of an examination of the 
bodies of 130 infants born dead or dying soon after birth, that pressure on 
the skull by the forceps or the uterine walls plays an important part in pro- 
ducing meningeal haemorrhage. He believes that when the bones of the 
skull are abnormally soft and the sutures lax, the lower edge of the parietal 
bone may press on the Sylvian vein or its connections, when the head is 
subjected to severe pressure during labour, and thus a haemorrhage in the 
Rolandic area may be produced (fig. 4). He also thinks that clamping of the 
internal jugular by the forceps or pressure on the infant's neck by the 
parturient canal may give rise to congestion and meningeal haemorrhage. 
It would appear from the observations of Spencer, that, while these cerebral 
haemorrhages are most common in severe and instrumental labours, they 
are not unknown in labours that are short and easy. The infant may live 
some days after the haemorrhage has taken place, as in a case recorded 
by McNutt ; the labour, which was a breech presentation, was easy ; the 
breathing became irregular on the day of birth ; later it suffered from con- 
vulsions, difficulty of swallowing, left hemiplegia, and emaciation. It died on 
the twenty-second day. At the post-mortem the right hemisphere was covered 
by a clot (see fig. 4), which was firm and gelatinous, and of a dark colour, 
the convolutions beneath it were in part destroyed, especially so in the ascend- 
ing frontal and parietal regions. The clot also invaded the brain substance, 
actually forming part of the roof of the ventricle, whilst the site of the corpus 
striatum and optic thalamus was occupied by a reddish-brown clot mixed with 
softened brain tissue. This case is remarkable as showing how long an 
infant may survive an extensive cerebral haemorrhage and the further damage 
by the secondary inflammatory softening which evidently took place. 

These are instances of fatal cases, but there is good reason to believe 
that such cases frequently survive, and bear for the rest of their lives traces 
of the damage done to their brains at birth. It is not difficult to imagine 
the damage which a surface haemorrhage may do. It may lead to com- 
pression of the convolutions, or meningitis, or softening, or it may more 
likely lead to atrophy, or interfere with the development of the convolutions- 
Such a case, verified by post-mortem^ has been recorded by McNutt. The 
infant was born with the feet presenting, the labour was tedious, and there 
was delay in disengagement of the head. Convulsions supervened, lasting 
for some days ; the child never walked or spoke ; there was spastic paralysis 
of both sides, except the face ; it died at two and a half years. Atrophy of 
the convolutions about the fissure of Rolando was found at the post-mot 
Similar cases are tolerably common ; there is a history o( a difficult labour ; 
the infant is blue, and perhaps is thought by the midwife to bo dead : it m,i\ 
be convulsed, but recovers. There is probably no marked paralysis at fust. 
1 Obstetrical Transactions, vol. xwiii. 



20 The Diseases Incident to Birth 

but after a few months it is noticed that an arm or a leg, or both legs, are 
weak ; then contractions take place, the legs becoming adducted, with the 
toes pointing, the forearms supinated, and the elbows more or less fixed. 
The intelligence is often affected, and the child is late in talking. Such 
cases are common in asylums, as recorded by Shuttleworth, 1 Schultze, 2 
Langdon Down,' 5 and others. That no definite symptoms of meningeal 
haemorrhage should be present at first agrees with what has already been 
remarked concerning the development of the cortical substance, and its 
connection with the ganglia at the base of the brain. Not only is the grey 
matter on the surface in an immature state, but so also is its connection with 
the lower parts. It is only a few months later, when the voluntary power is 
being put forth, that it is noticed that there is any difference between one 
limb and another. Convulsions may be present, and if there is any marked 
paralysis it is probably peripheral, being caused by effusion of blood at the 
base of the brain on the pons or cervical cord. 

Haemorrhages into other Viscera. — Spencer found in his post-mortem 
examination of stillborn children haemorrhages into the lungs, liver, kidneys, 
intestines, testis, &c. In the lungs the most frequent site was the base, the 
appearance being that of ordinary pulmonary apoplexy, the haemorrhagic 
portions being solid and of a black red colour on section. If the infant 
lives pneumonia may arise. 

Haemorrhage taking place into the kidney may cause death during the 
first few days of life by suppression of the urine (Spencer). 

Haemorrhage into the bowels may cause obstruction. 

Cephalhematoma. — During birth a haemorrhage may take place from 
the vessels of the periosteum of the skull, and a collection of blood form 
between that membrane and the bone ; more rarely a haemorrhage occurs 
between the occipito-frontalis aponeurosis and the periosteum, or between 
the skull and the dura mater. The name ' cephalhematoma externum ' is 
applied to the first two, thus : 

Cephalhematoma externum . ( r - Subaponeurotic 

I 2. Sub-penosteal. 
„ internum . . 3. Sub-cranial. 

Meningeal haemorrhage ... 4. Sub-arachnoid. 

In the common form the tumour is sub-periosteal. The swelling, 
occupying a position immediately over a parietal bone, generally the right, 
is usually discovered for the first time a day or two after birth, when the 
swollen and distorted head of the infant should begin to assume a more 
natural shape. According to the statistics of Hennig and Hofmokl, a cephal- 
haematoma occurs about once in every two hundred births ; in one hundred 
and twenty-seven cases noted by Hennig, it was situated fifty-seven times 
over the right parietal bone, thirty-seven times over the left, twenty-one times 
over both, seven times over the occipital, three times over the frontal, and 
twice over the temporal bone. It forms a more or less tense elastic tumour, 
neither hot nor tender, and it does not extend beyond the limits of the bone 
over which it is situated, inasmuch as the periosteum is firmly attached 

1 British Medical Journal, vol, i. 1886, p. 185. 2 Gerhardt's Handbook, vol. ii. 

5 British Medical Journal, vol. i. 1877, Feb. 24, 



Cephalhematoma 



21 



to the sutures. The scalp is not discoloured. The tumour varies in size from 
a walnut to a small orange, increases in bulk for a few days after birth, and 
then begins slowly to diminish. After it has existed for a week or two, 
a ridge of bone may generally be felt at its circumference, where new bone 
has been thrown out by the perios- 
teum (see fig. 6 c'). When the 
tumour is examined for the first time 
in this stage, it is apt to give the 
impression that there is a circular 
defect in the parietal bone, through 
which a fluid tumour is protruding. 
At times, especially in chronic cases, 
thin plates of bone form here and 
there in the periosteum forming the 
roof of the tumour and give rise to 
a feeling of crepitation when it is 
handled. In the course of a few 
weeks or a month the tumour 
shrinks and disappears, leaving for 
perhaps many months a more or 
less complete bony ridge, which 
marked the circumference of the 
tumour. The etiology of these 
blood-swellings is not very clear, but, like other haemorrhages which take place 
during birth, they owe their production in part to asphyxia, in which there is 
increased tension in the cranial veins, and a condition of blood which readily 
allows of extravasation. From the fact that the tumour mostly occurs at the site 
of the caput succedaneum, being over the right parietal bone in nearly three- 
fourths of the cases, it would appear that pressure upon the head played an 




^.-fcT* 



Fig 



Double Cephalhematoma in an Infant 
rwenty days old (from a photograph). Labour 
difficult, forceps applied, right facial paralysis. 




Fig. 6.— Section of a Cephalhematoma (semi-diagrammatic), Hennig. <t, Dura mater 
/>, parietal bone ; c, periosteum ; <', ossification of ditto ; d, scalp : e, blood clot. 



important part in its causation ; but, on the other hand, cases arc reported 
in which a blood-swelling appeared over a parietal bone in a case oi breech 
presentation (Runge, McNutt). Small extravasations, the si/e oi a pea or a 
shilling, may frequently be seen beneath the periosteum in making post- 
mortems on newly born infants. If the caput succedaneum be incised, the 
tissues immediately beneath the scalp will be found infiltrated with a jelly- 
like effusion with numerous minute haemorrhages scattered through it, and 



22 The Diseases Incident to Birth 

on examining the parietal bone numerous small haemorrhages may be seen 
beneath the periosteum, some linear in shape, corresponding with the lines 
or foramina in the bone situated near the inter-parietal suture or posterior 
fontanelle. According to Fere the edges of the foramina play an important 
part in wounding the vessels during labour, and producing a haemorrhage, 
as they are the means of transmitting small veins from the scalp to the 
cerebral sinuses. It is important to bear in mind that not infrequently an 
effusion of blood external to the skull communicates with an effusion of 
blood between the bone and dura mater through one of these openings, and, 
further, a meningeal haemorrhage may also take place. 

Three post-mortem examinations made by Runge are worth recording, as 
illustrating some of these points : (i) breech presentation ; delay in deliver- 
ing head ; infant born in condition of asphyxia ; died on the eighth day in 
convulsions. The post-mortem showed a cephalhematoma over the left 
parietal bone surrounded by a bony ridge ; a large haemorrhage over the 
convexity of the brain beneath the dura mater, reaching to the base and 
upper part of the cervical cord. (2) A premature infant delivered by forceps 
in consequence of maternal eclampsia ; born asphyxiated, died on the first 
day ; there was a cephalhematoma over the right parietal bone, communi- 
cating through a fissure in the bone with a second effusion of blood beneath 
the bone between it and the dura mater. There was also meningeal haemor- 
rhage. (3) Infant born asphyxiated, reanimation, death on the sixteenth day 
from arteritis umbilicalis. There was a cephalhematoma, covering the whole 
of the right parietal bone ; a hard bony wall roofed in the circumference of 
the swelling. A surface hemorrhage had taken place at the base of the brain. 

The diagnosis is not generally a matter of difficulty. A blood tumour 
beneath the periosteum is distinguished from a caput succedaneum, inasmuch 
as the latter does not fluctuate, disappears in a day or two, and extends 
beyond the limits of a parietal bone. It is distinguished from a meningocele in 
that the latter corresponds to a suture or fontanelle, pulsates, and increases in 
size when the infant cries. Very rarely a blood swelling takes place beneath 
the scalp, between the latter and the periosteum. In such cases the scalp is 
discoloured, no bony ring would be formed, and the swelling might extend 
beyond the sutures. The prognosis as far as a cephalhematoma is con- 
cerned is favourable, but inasmuch as it is possible that it is complicated by 
meningeal or extra-dural hemorrhage the prognosis must be guarded, and 
any brain symptoms are necessarily of evil omen. 

Treatment. — The treatment of these blood swellings has been much 
discussed. On the one hand, it has been urged that if the cephalhematoma 
is subperiosteal, it should be aspirated without delay while the blood is 
fluid and before coagulation has taken place, as in this way the long delay 
during which absorption and deposition of bone are taking place is avoided. 
On the other hand, it has been pointed out that it is never possible to tell if 
the blood swelling does not communicate with a blood extravasation within 
the skull, thus rendering surgical interference risky, and moreover that, 
although absorption of the effused material may be tardy, it is both safe and 
sure, and a good result may be confidently looked forward to. The latter 
course is certainly to be recommended; surgical interference in a newly born 
infant always has its risk, there is always the possibility of introducing 



Stemo-mastoid H&matoma — Occipital Uamatoma 23 

septic organisms into the blood swelling by aspiration, and at the most all 
that is to be gained by such a proceeding is the saving of a few weeks of time. 
We believe that all cephalhaematomata are most safely Jet alone, care being 
taken to protect them from injury ; small ones may be shaved and painted 
with collodion, or during sleep some spirit lotion may be kept applied. In 
the rare event of their suppurating the treatment would be that of an ordinary 
abscess — viz. evacuation of the pus and drainage. 

Haematoma of the Sterno-mastoid. — If an attempt be made by an un- 
skilful midwife to disengage the after-coming head by pulling on the legs or 
body of the infant, there is a strong probability that injury will be done to 
the neck or other part, especially as the muscles of the semi-asphyxiated 
infant are flabby and toneless, and the blood readily oozes out of the vessels. 
Such an injury does at times take place, giving rise to a blood tumour within 
the sheath of one of the sterno-mastoids in consequence of the tearing through 
of some of the fibres of the muscles orinjury to some of its vessels. It is not 
often that an opportunity occurs of verifying this condition post mortem, 
inasmuch as no serious consequences arise from the accident, but the 
investigations of Tordeus, Spencer, and others make it clear that these 
swellings are due to local haemorrhage resulting from injuries at birth. In 
one of our own cases in which the infant died of diarrhoea when six months 
old, a cicatrisation of the muscle at the spot where the injury had taken place 
was found. In another case we had also the opportunity of a post-mortem. 
At least three-fourths of these cases are breech presentations : in the re- 
maining fourth, which occur in head presentations, the injury is no doubt 
caused by dragging on the head in order to disengage the shoulders and 
body. The swelling in the neck may be noticed by the mother a few days 
after birth, or it may escape observation for some weeks, or even more. On 
examination a tumour about the size of a pigeon's egg may be felt in the upper 
part of the right sterno-mastoid; it is generally irregular, or perhaps elongated, 
in shape, and if not seen for some time after birth, when cicatrisation has taken 
place, it is hard and cartilaginous to the touch. The left muscle is less often 
injured than the right ; sometimes the whole length of the muscle is affected, 
though the lesion is generally in the upper part. The tumour disappears in 
the course of a few months, but for a long time a cicatrix may be felt. 
There is no treatment required. These cases mostly occur among the 
poorer classes, who are attended in their confinements by neighbours or 
unskilled midwives. Injury to the sterno-mastoid during birth derives its 
importance from the fact that such injury is likely to be the cause of wry neck 
in after life (see Torticollis). 1 

Occipital Haematoma. — Injury toother muscles may occur during birth, 
and we have seen in one case a 'tumour' in connection with the muscles at 
the back of the neck arising from injury during birth. It was a head 
presentation and there was also a sterno-mastoid 'tumour.' The child was 
seen at five weeks old. Labour had been prolonged, head delivered by forceps 
with much difficulty, and subsequently severe traction was needed to extract 
the body. Two symmetrical swellings were felt in the muscles at the back 
of the neck, evidently due to haematoma. There was left facial paralysis and 

1 See also D'Arcy Power, Med.-CAir, Trams, vol. Ixxvi. who gives .1 list ofcas< 
Clutton and others' observations as well as las own. 



24 The Diseases Incident to Birth 

paralysis of the left arm. The child was heard of two years later, and it was 
said to have completely recovered. 

Obstetrical Paralyses. — In cases of delayed labour, where the forceps 
have to be applied, or where force is used to disengage an arm or traction 
is applied to it, some nerves or strands of nerves are apt to be injured either by 
stretching, direct pressure, or compression by extravasated blood. The most 
common and best known is an injury to one of the facial nerves through pres- 
sure exerted by one of the blades of the forceps during extraction. A facial 
paralysis is thus produced, which as a rule is temporary, and disappears in a 
few days or weeks. The other and less common form, which has been de- 
scribed by Duchenne as ' obstetrical paralysis,' is due to an injury to one or 
other of the cords of the brachial plexus, produced by the pressure of the finger 
hooked in the axilla in order to extract the arm and shoulders, or the arm has 
been forcibly wrenched when it has been used to lay hold of to drag the infant 
through the pelvis. Occasionally an injury may be done to the brachial plexus 
as well as to the facial by the grip of the forceps blades, as in a case recorded 
by Roger, where the face and arm were paralysed. After death an effusion 
of blood was found at the stylo-mastoid foramen, and also round the cordsoi 
the brachial plexus. The cord most often injured is apparently the fifth cer- 
vical nerve, which, as Ross has shown, is readily injured, at the point where 
it descends over the transverse processes of the fifth and sixth cervical ver- 
tebrae on its way to join the brachial plexus, by force applied to the arm or 
clavicle. The prognosis in paralysis of the arm from a lesion of the brachial 
plexus is more serious than it is in paralysis of the face, but it will neces- 
sarily vary according to the amount of injury done and the degree of para- 
lysis present. The symptoms presented by this form of paralysis may be 
illustrated by the following cases which came under our notice : 

In the first case, the head, according to the mother, was born first ; there 
was then a delay ; finally the left arm was disengaged by the finger hooked in 
the axilla, and the child born after some delay and difficulty. The infant was 
first seen when seven weeks old. At this time its arm hung uselessly by its 
side, the elbow extended, the humerus rotated inwards and adducted, the 
forearm pronated, the hand closed, the paralysed muscles being the biceps 
and brachialis anticus, the infra-spinatus and teres minor, the deltoid and 
supinators. The muscles affected were soft and flabby. The arm was 
regularly galvanised, the Faradic current being used. Three years afterwards 
great improvement had taken place ; the elbow could be flexed and the hand 
could be used, but a paresis remained of the deltoid and supinators. In 
another case, seen ftrst at ten weeks of age, the same muscles were paralysed, 
much improvement took place, but the infant died at six months old of 
bronchitis. In a third case, which was a footling, the left arm engaged the 
pelvis with the head, and had to be brought down by the accoucheur. The 
arm was noticed to be bruised and useless after birth. Unfortunately this 
case was lost sight of. In another case seen by us, both arms were almost 
completely paralysed, only the fingers in one hand retaining some power of 
flexion. The mother had a contracted pelvis, the head presented, the medical 
man turned and delivered with much difficulty ; there was also a sterno- 
mastoid haematoma. In two cases reported — one by Seeligmliller, the other 
by Thorburn — the paralysis was more extensive than in the above cases ; 



Icterus Neonatorum 25 

there was also retraction of the eyeball and contraction of the pupil of the 
same side. Probably there was here a more severe injur)-, involving the 
whole brachial plexus and also the sympathetic. In some cases a temporary 
anaesthesia has been noticed. In the treatment of these cases it must be 
borne in mind that one or more of the cords of the brachial plexus has been 
injured, accompanied by a local haemorrhage ; and therefore, the more at rest 
the arm can be kept for the first few weeks the better. It seems doubtful if 
any shampooing or galvanising of the muscles can at first do much good. 
The treatment must be rather that of a fractured bone — rest at first, and 
afterwards more or less active movement to exercise the muscles and prevent 
stiffness. The arm should be carefully wrapped up in cotton wool, flexed and 
supported by being fixed to the side, care being taken to prevent undue 
disturbance during the daily bath, or allowing it to hang down and drag on its 
connections with the trunk. It must be borne in mind that the circulation 
of blood will be sluggish, and easily obstructed by tight bandaging. At the 
end of three weeks, when there is reason to believe that absorption of the 
effused blood has taken place, movements of the arm may be begun, in order 
to give the muscles some exercise and to call forth the voluntary efforts of 
the child. Galvanism, shampooing the muscles, applying stimulant applica- 
tions to the skin, must be persevered with as long as any improvement takes 
place. The prognosis in the severe cases is gloomy as far as the paralysed 
muscles are concerned, the arm remains in a condition of extension and 
pronation, and is unable to be raised to the mouth. In other cases, as in 
the one mentioned, recovery takes place sufficiently to allow of flexion of the 
elbow, though a certain amount of weakness may be left about the shoulder 
and in the supinators of the wrist. In the slighter cases considerable 
improvement may be expected in the course of months or years. 

Icterus neonatorum, — Infants often suffer from a more or less pro- 
nounced jaundice which comes on a day or two after birth. It has been 
estimated by Continental writers that this occurs in from 60 to 80 per 
cent, of the total births ; but these observations have been mostly made in 
lying-in hospitals, where it appears to occur much oftener than in private 
practice, though there is little doubt that on account of the slightness of the 
yellow coloration of the skin, and the frequent absence of discoloration of 
the sclerotic, it may easily be overlooked. Jaundice may arise from or be 
symptomatic of various pathological conditions, the principal during the first 
week of life being the following : 1. The common form in which no disease 
is apparent — icterus neonatorum. 2. Jaundice accompanying a condition 
of septicaemia or pyaemia ; in acute fatty degeneration of the newly born : 
in Winckel's disease. 3. Jaundice due to congenital stricture, or oblitera- 
tion of the common or hepatic duct, or to syphilitic perihepatitis. The 
common form to which the name of 'icterus neonatorum 3 is generally 
applied differs from the other forms in not being accompanied by any serious 
symptoms, and in passing off in a few days or a week. In these cases the 
yellow coloration of the skin makes its appearance on the second day, less 
often the third, rarely either before the second or after the third, and lasts, 
according to its intensity, from two or three days to a week. The yellow ness 
is first noted on the face, around the mouth anil chest, then on the abdomen, 
later on the limbs ; it ma)- be easily overlooked, unless pressure is made by 



26 The Diseases Incident to Birth 

the finger on the skin. In mild cases the sclerotics remain unaffected, and 
the urine does not stain the linen ; this is the more noteworthy, as in the 
jaundice of adults the sclerotics are affected before the skin is tinged, and 
pigment is very early present in the urine : probably the vascularity and 
transparency of the infant's skin account for the difference. When the 
jaundice in the infant is more intense, the sclerotics become tinged ; the 
urine stains the diapers, and bile pigment may be detected. The stools are 
unchanged and contain the usual quantity of bile. In cases which die when 
suffering from this form of jaundice, the internal organs are found stained 
yellow, especially the cartilages, the brain, and in a lesser degree the abdo- 
minal viscera. The majority of infants who are jaundiced appear in perfect 
health ; it has, however, been asserted by Hofmeier that infants with icterus 
do not flourish as well as other infants, that their loss of weight during the 
first week is greater than that of healthy infants, and that a higher per- 
centage of urea and uric acid appears in the urine. The cause of this form 
of jaundice is uncertain ; it is much more frequent in lying-in hospitals 
than in private practice, and in premature weakly infants with partially 
expanded lungs than in full-time and healthy infants. There have been 
many hypotheses concerning its cause, but none of them are entirely satis- 
factory. One of the most plausible explanations has been suggested by 
Quincke ; he attributes the jaundice to the ductus venosus remaining patent, 
thus allowing some of the portal blood (which contains bile pigments) to pass 
into the general circulation, instead of all of it being submitted to the action 
of the liver. Virchow and others believe it to be a haematogenous jaundice, 
the bile pigment originating in a destruction of blood corpuscles which it is 
supposed takes place shortly after birth. 

While this form of jaundice \s per se a symptom of little importance, and 
in the vast majority of cases the infants do well, it is well to remember that 
occasionally cases occur which are jaundiced shortly after birth, and which 
■die about the ninth or tenth day without any definite disease being discover- 
able. These cases sometimes occur in the same family, as in the following 
remarkable instances : the father and mother were both healthy and in com- 
fortable circumstances, there was no history of syphilis, the first and second 
children were never jaundiced, and are at present alive and well ; the third, 
fourth, fifth, and sixth children became jaundiced on the second or third day, 
and died on the ninth or eleventh day. In all, the skin and conjunctivae 
were jaundiced, the urine contained bile pigment, the stools were normal. The 
fifth child was seen with Mr. G. H. Pinder, their medical attendant, when five 
days old ; it seemed a perfectly healthy infant, except that it was jaundiced. 
The infant became weaker and drowsy, and died comatose on the ninth day. 
A partial post-mortem only was obtained ; the abdominal viscera were bile- 
stained ; the ductus venosus was only partially closed ; there was nothing 
abnormal about the bile-ducts. What is the nature of these and similar 
cases it is at present impossible to say. The diagnosis between icterus 
neonatorum and the jaundice which accompanies septicaemia does not 
present much difficulty, for in the latter case there would be some suppura- 
tion or phlebitis of the umbilical cord or ecchymosis and various haemor- 
rhages. In acute fatty degeneration and Winckefs disease there are usually 
•cyanosis, purpuric spots, and haemorrhages. In jaundice from obstruction of 



Hemorrhagic Diathesis — Hcemophilia Neonatorum 27 

the ducts, the jaundice is intense and bile is absent from the stools. Nothing 
much can be said about the treatment of infantile jaundice, which consists 
rather in attending carefully to the general health of the infant than in the 
administration of any special drug. Small doses of hyd. c. cret. may be 
given for its laxative effect, and to relieve any tendency to mechanical con- 
gestion of the liver. 

Haemorrhagic Diathesis. Haemophilia Neonatorum. — It not infre- 
quently happens that within a few days of birth the infant exhibits a tendency 
to bleed, There may be haemorrhages from the nose, stomach, bowels, 
or kidneys, and petechia; and ecchymoses may make their appearance on the 
skin. Oozing of blood, which is perhaps difficult to arrest, may take place 
from the navel on the separation of the cord. This tendency to bleed is no 
doubt to be looked upon as rather a symptom than a disease or the result of 
disease. It cannot be said that our knowledge is very exact regarding the 
conditions which give rise to the haemorrhagic diathesis in infants, but in a 
large majority of cases at least the infant is either syphilitic or suffers from 
septicaemia or from both conditions. The poisons generated by the syphilitic 
or septic infection appear to cause such changes in the blood as give rise 
to bleeding on the slightest injury. In some of the cases in which there was 
no evidence of syphilis during life, the evidence has been forthcoming at the 
post-mortem, and, moreover, syphilis is not disproved by no lesions being 
discovered in an infant a few days old. 

In seven cases recorded by Fischl * in which haemorrhages took place 
shortly after birth from the mucous membranes or into the skin, there was 
evidence of syphilis ; there being characteristic rashes on the skin, enlarge- 
ment of the spleen, and interstitial hepatitis. In one of the author's 
cases, however, the only evidence of syphilis was the enlargement of the 
spleen and an interstitial hepatitis. A careful microscopical examination of 
the minute blood-vessels was made in these cases, with the result that they 
were found normal, so that the bleeding could not be attributed to arteritis. 

In three cases of haemophilia in infants recently investigated by H. 
Neumann, 2 pyogenic organisms were found, and the author inclines to the 
belief that the entrance of the septic organisms into the system either before 
or during the act of birth had much to do with the haemorrhagic state. In 
the first case the infant, which was illegitimate, suffered from jaundice, petechia: 
on the skin, melaena, and haematemesis ; it died on the fifteenth day. The 
autopsy showed there had been capillary bleeding from the mucous mem- 
brane of the alimentary canal, enlargement of the spleen, and interstitial 
hepatitis (syphilitic). A bacteriological examination of the blood showed the 
presence of the Bacillus pyocyaneus ft. In a second case, undoubtedly 
syphilitic (snuffles and rash), which suffered from bleeding from the nose and 
mouth, and which died when seven weeks old, a bacteriological examination 
showed the presence of pus cocci, namely, Staphylococcus Pyogenes aureus 
and albus and also Streptococcus pyogenes. In a third case, in which the 
mother suffered from syphilitic ulceration of the Libia, the infant suffered 
from jaundice and various haemorrhages, and died on the ninth day. Both 
bacilli and cocci {Bacillus pyocy an, ft and Staphyloc pyog, aureus) were 

1 ArchivfUr Kinderheilk. Band viii. 

- Ibid, lxuule xii. \iii. 



28 The Diseases Incident to Birth 

found in the blood. It is not easy to say in the present state of our know- 
ledge whether the bacilli and cocci found were accidentally present, or 
whether they were directly or indirectly the cause of the blood change which 
gave rise to the blood extravasations. The bacilli may enter the foetal tissues 
before birth through the placental circulation or be inoculated at the time of 
birth or afterwards through the navel. 

Acute Fatty Defeneration of the Newly Born. — Buhl, in l86l, de- 
scribed the symptoms and morbid anatomy of a rare disease, occurring in 
newly born infants, to which he gave the name of acute fatty degeneration. 
His observations have since been confirmed by Hecker, Furstenburg, Roloff, 
and Runge, though it cannot be said that this condition is sufficiently well 
known for it to take its place as a well-defined and definite disease. The 
infants suffering from it are generally born in a condition of asphyxia with- 
out obvious cause, and some die asphyxiated. If they survive, they usually 
suffer from more or less cyanosis, with haemorrhage from the bowels, 
stomach, or from the na\ el on the separation of the cord. There is often 
jaundice, and blood extravasations take place beneath the skin, conjunctiva, 
or mucous membrane of the mouth ; there may be general oedema ; death 
usually takes place within two weeks. At the post-mortem minute haemor- 
rhages are found in the various internal organs, which are sometimes infil- 
trated with blood ; the tissues are bile-stained. On microscopical examina- 
tion of the tissues of the heart, liver, kidneys Sec. they are found to be in a 
condition of fatty degeneration. The nature of the disease is quite unknown. 
It is interesting to note that a similar condition has been observed in newly 
born pigs and other domesticated animals. 

"Winckel's Disease. — A disease somewhat similar to the last has been 
described as occurring in an epidemic form by Winckel, and is characterised 
by cyanosis, jaundice, and haemoglobinuria. This epidemic occurred in the 
Foundling Hospital at Dresden in 1879, .where twenty-three infants were 
affected in the course of a month. The symptoms noted were first of all a 
bluish tinge on the skin of the face, body, and limbs, with a more or less 
icteric tint ; in some cases there were vomiting and diarrhoea. The urine 
was of a light brown colour, with a sediment consisting of epithelium and 
casts ; the blood contained an excess of white corpuscles and many granular 
bodies. The symptoms usually began on the fourth day after birth, death 
occurring in one case in nine hours, though the average duration of the 
disease was about two days. The sections showed a yellow staining of the 
skin and internal organs. The spleen was large and hard and dark red ; 
the kidneys were usually dark brown in colour, the microscopic examination 
showing their tubules to be filled with granular pigment. There were puncti- 
form haemorrhages on the surface of the various internal organs, and fatty 
degeneration of the liver and heart. 

Gastro-intestinal Haemorrhage. — The vomiting of blood, or its passage 
per anum, is not an uncommon occurrence in the newly born. The most 
common cause, especially of haematemesis, is the swallowing of blood oozing 
from a cracked nipple, which the infant sucks, or from some wound in the 
infant's mouth or nose. Large quantities of blood may be swallowed in this 
way, and vomited in a more or less altered condition, or passed as blackish 
masses with the faeces. A haemorrhage may have taken place into the 



G astro-intestinal Hemorrhage — Umbilical Polypus 29 

bowel during labour and the blood passed in the stools. A much more 
serious condition exists when the source of the bleeding is a small ulcer or 
ulcers in the stomach or duodenum, which may open a large vessel and 
cause fatal haemorrhage, as in a case recorded by Goodhart and another by 
Sawtell. Neumann has recorded a somewhat similar case in an infant 
born of healthy parents, which died on the third day from birth after 
vomiting blood. At the post-mortem an ulcer was found in the duodenum. 
In the majority of cases the bleeding appears to be capillary, due to a 
tendency to haemophilia, which has been described (p. 27). The haemorrhage 
in most instances comes on within the first twenty-four hours ; if the 
amount of blood lost is large, the infant quickly becomes pallid, the skin 
cold, the fontanelles depressed, and convulsions probably follow. Death 
usually takes place within twenty-four hours of the commencement of the 
symptoms ; if the infant survives this period and no fresh attack comes on, 
there is reason to believe there is no lesion of the stomach or duodenum, 
and there is good hope that the infant may survive. The treatment would 
naturally depend upon the diagnosis as to the cause. Small doses of 
ergotine (quarter grain to half grain), in syrup, by the mouth or sub- 
cutaneously, would be the most likely to be of service. In any case of 
passage of blood per rectum in an infant, the possibility of an invagination 
of the intestine must be borne in mind. 

Haemorrhage from the Genital Organs. — It sometimes happens that 
there is a small oozing of blood from the vagina during the first few days 
succeeding birth, sufficient to stain the napkins. The blood may often be 
seen oozing from the vagina, while no lesion of any kind can be detected. 
The discharge lasts for a few days only, generally from two to five, the health 
of the infant does not suffer, and recovery seems always to take place. 
Cullingworth has collected thirty-two such cases, two of which came under 
his own observation. He agrees with Cameron in believing that the bleed- 
ing is due to a congestion of the pelvic veins, the result of the cessation of the 
circulation in the umbilical arteries when the cord is tied. As already stated, 
there is sometimes a coincident discharge of blood from the rectum, due 
apparently to the same cause (see also p. 20). It must not be forgotten that 
cases of precocious menstruation may occur, commencing shortly after 
birth, and continuing monthly afterwards. 

Diseases of the Navel. Separation of the Cord. — Under ordinary 
circumstances the umbilical cord shrivels up and drops off at a period after 
birth varying from the first to the fifth day, thin small cords drying up and 
separating earlier than large soft ones (Bouchut) ; the cicatrix is not usually 
dry and firm until the tenth or twelfth day. 

Umbilical Polypus. Occasionally, after the cord has separated, a small 
red prominent projection is left with a moist surface, and sometimes v l [olmes) 
a fine central canal ; this ' polypus ' is the result in most cases of incomplete 
withering of the cord, at other times the outgrowth is rather of the nature oi 
a simple granulation polypus from irritation, the so-called ' fungus of the 
navel.' The projection, when small, is often hidden by the overhanging 
skin of the part, and may remain for weeks or months, giving rise to slight 
discharge from the scar and perhaps excoriation ot the skin around. In 
another class of cases such as one sent to us by Dr. Serra, of Eccles, the 



3Q 



The Diseases Incident to Birth 



proximal part of the cord instead of shrivelling up remained as a red vascular 
projection some three inches long. On examining this child some five or six- 
weeks after birth, there was a red fleshy prominence then about i^ inch long- 
projecting from the navel ; it was about as thick as a cedar pencil, and its 
surface appeared to be a mucous membrane except at one spot where a patch 
of delicate cuticle was found. The apex of the protrusion was perforated by 
an orifice which readily admitted an ordinary probe, and the instrument 
could be passed downwards in the middle line and swept round on each 
side for some three inches ; it could only be passed upwards for about half an 
inch. A thin watery mucus in small quantities was discharged, but no faeces 
or urine. Subsequently faecal matter escaped from the orifice. The pro- 
truded mass was ligatured and re- 
moved with a good result. This 
condition is due no doubt to persis- 
tence of the vitelline duct in the 
proximal part of the cord and its 
conversion into intestine ; it com- 
municates with the ileum by means 
of Meckel's diverticulum. After the 
distal part of the cord has become 
detached the end cicatrises, and a 
prolapse takes place of the whole 
thickness of the tube ; hence in the 
section in fig. 7 two layers of mucous 
membrane with an intervening mus- 
cular and fibro-cellular layer are 
seen. Such cases are not rare ; we 
protrusion ; was not so large as in the 

A section 




Fig. 7. — Section of Ileo-umbilical Diverticulum. 
a, central canal continuous with Meckel's 
diverticulum lined with villi ; b, remains of villi 
of the everted portion of mucous membrane ; 
c, tubular glands ; d, remains of muscular 
coats ; e, section of blood-vessels ( x 4). The 
muscularis mucosae layers are also seen. (Dr. 
Serra's case.) 



have met with several, in which the 

above case, but from which there was a thin biliary discharge. 

after excision showed traces of muscular fibres and columnar epithelial 

cells. 

We have seen a similar case in a child of six years old, but the parents 
declined any interference. Huttenbrenner describes another variety as a 
remnant of the allantois. In these it is said urine may escape externally in 
consequence of the urachus remaining patent, and such cases have been and 
are spoken of by some writers under the name of ' navel-urachus fistulge. 
but we have never seen a case in which there was sufficient evidence of any 
connection with a persistent urachus. 

The treatment of these affections is very simple : for the larger ones a 
ligature should be applied tightly round the base, and the mass cut short 
off; the smaller ones may be snipped off with scissors or rubbed down with 
nitrate of silver, or dusted over for a few days with powdered nitrate of lead,, 
which we have found an effectual remedy. It must be remembered that 
there is considerable variation physiologically in the process of separation 
of the cord ; in weakly children it falls off later and the raw surface is slower 
in healing. Where the cord stump is projecting it is liable to be irritated 
by friction and its healing is slow : this is the condition described as 
excoriation. When a sort of ' mucous surface : remains and goes on dis- 
charging, the so-called Blennorrhag-ia exists, while the presence of a thick. 



Omphalitis — Gangrene 3 1 

consistent film on the surface of the sore has been described as croupous or 
diphtheritic exudation ; in some instances it is probable that a true 
diphtheritic membrane is formed. 

Where there is any spreading ulceration after separation of the cord, in- 
fective influences should be looked for ; the mischief may spread superficially 
or it may tend inwards and involve the peritoneum. A mere superficial ex- 
coriation of the skin analogous to intertrigo elsewhere is often seen in older 
children as a result of dirt and neglect. It is readily cured by the applica- 
tion of boric powder. 

Simple ulceration is never fatal unless it extends deeply ; it should be 
treated, according to Runge, by the application of salicylic acid and starch 
— 1 in 5 for the milder cases, or 1 in 3 if there is any sloughing ; ointments 
he disapproves of. 

Omphalitis is a rare condition. When it exists the navel itself and the 
surrounding parts are inflamed and swollen, the wound remains unhealed, 
and the skin around is red, shiny, tense, and painful. The disease may 
spread and involve nearly the whole of the abdomen either superficially or 
throughout the entire thickness of the abdominal wall ; the infant becomes 
very ill, the legs are stiff and drawn up, breathing is thoracic, and small 
abscesses may form and burst from time to time. The disease begins in the 
second or third week of life and may last for some days or even weeks. 
The prognosis is good if the extent of mischief is small and suppuration occurs 
early, bad if the disease is widespread, and especially if it tends inwards 
towards the peritoneum ; if the navel vessels are involved, general sepsis 
or gangrene is likely to result. The younger the child the greater is the 
danger. 

The cause of this disease is doubtful. Probably it arises from bad 
management of the navel and infection. Fribe believes some cases to be 
syphilitic. Is it possible that some may be instances of sloughing phage- 
dena ? According to Bouchut it is sometimes complicated by bleeding. 
Treatment consists in cleanliness and the application of salicylic acid be- 
neath a warm wet dressing (Runge). All abscesses should be opened early, 
and any tendency to gangrene met with stimulants and antiseptics. 

Gangrene of the navel begins either as an ulcer or as omphalitis ; it 
occurs also in cases of cholera infantum ; as a purely local condition it is 
rare, and Wiederhofer believes that it arises from intense omphalitis. Pre- 
mature separation of the cord and irritation tend to produce gangrene. 

The disease usually begins as a blister containing muddy fluid : on 
bursting this leaves an ulcer, or a sore may exist from the first ; the mischief 
spreads rapidly either superficially or deeply ; a bright red zone is seen sur- 
rounding a central slough, which after a time comes away ; there is rapid 
prostration of strength, though but little pyrexia. Recovery from gangrene 
of the navel is rare, though sometimes the slough separates and the cavity 
granulates up ; more often death results from peritonitis or exhaustion, or 
again from gangrene of the bowel and perforation, which is sometimes met 
with ; occasionally a faecal fistula is formed.' In many eases general sepsis 
occurs, and Ritter believes the gangrene is merely a result of the septic con- 
dition. In cholera infantum there is sometimes rapid gangrene without an) 
1 In one remarkable case an intussusception occurred through a t'.ival fistula. 



32 The Diseases Incident to Birth 

sign of reaction, and this may occur as late as several months after birth ; it 
is always fatal. 

The treatment of gangrene consists in free stimulation and the use of 
antiseptics ; nitrate of silver, perchloride of iron, and salicylic acid are recom- 
mended by Runge, to whose work, ' Die Krankheiten der ersten Lebenstage,' 
we are indebted for nearly all our information on these diseases. Faecal 
fistula, if the child survives, should be treated as in older children. 

Umbilical Arteritis. — In fifty-five subjects of disease of the umbilical 
vessels Runge found fifty-four cases of arteritis, and in only one was there 
phlebitis alone. The mischief begins as inflammation of the cellular tissue 
round the vessels, and then spreads to them, producing thrombosis. Pelvic 
cellulitis, which sometimes occurs, is the result of septic lymphangitis spread- 
ing directly along the cellular tissue, and is not due to embolism. 

Birch Hirschfeld believed in phlebitis as a common affection, but Runge 
points out that the greater frequency of arteritis is due to the fact that the 
area of cellular tissue surrounding the arteries is twice as great as that round 
the veins. Inflammation in cases of arteritis may spread far and wide from 
the navel, and even reach the bladder or its neighbourhood. Where arteritis 
exists the navel presents often a projecting discoloured ulcer covered with a 
scab ; sometimes, however, the scar is healed and quite natural in appear- 
ance. The disease may arise either before or after separation of the cord, 
and suppuration and sloughing may occur. 

Sometimes the lumen of the arteries is seen open, and the vessels are full 
of pus or breaking-down clot ; suppuration usually spreads along the vessels 
as far as the cellulitis extends, beyond this adherent coagula are found. At 
times the arteries are pouched, and the sacs formed are found full of pus : 
the intima of the vessels is always dull and has lost its polish. 

The most common complication of the disease is pneumonia ; this was 
found in twenty-two of Runge's fifty-five cases ; septic inflammatory foci 
may, however, also occur in the liver, spleen, kidneys, peritoneum, bones, and 
joints. &c. Erysipelas sometimes attacks the part, and slight jaundice is 
common,- though severe jaundice with hepatitis is rare. Of Runge's fifty-five 
cases, in nine there was arteritis alone, in sixteen there were complications, 
such as syphilis, ' atrophy; cerebral haemorrhage, &c, and in the remaining 
thirty cases there were pyaemic lesions. Buhl, Wiederhofer, and Muller 
differ from Runge in thinking that usually the disease affects only the abdo- 
men and its v ; scera. Peritonitis is to be suspected as soon as distension 
appears. Tetanus is an infrequent complication. Arteritis is a disease of 
dirt and neglect ; it occurs in epidemics, and is often associated with puerperal 
fever ; it maybe inoculated by the lochia or decomposing umbilical cord, and 
has been found associated with ophthalmia neonatorum. It usually runs a 
rapid course, lasting from four to eighteen days, and is especially fatal to 
young and premature children ; in older infants the prognosis, though bad, 
is not absolutely so ; in fatal cases death is usually sudden. 

Umbilical Phlebitis. — As already pointed out, umbilical phlebitis is a 
rare disease. Birch Hirschfeld, in examinations of sixty infants who died of 
septic diseases beginning in the navel, found eleven cases of phlebitis, four 
cases of simple thrombosis of the vein, and thirty-two cases of arteritis, while 
in three instances both the arteries and vein were involved. Runge has only 
twice seen phlebitis apart from arteritis. 



Umbilical Phlebitis — Umbilical HcemorrJiage 33 

The general appearances of phlebitis are very like those of arteritis : there 
is thickening of the perivascular tissue, the lumen of the vein is diminished ; 
it is tortuous and contains pus or sanious material, the intima is cloudy 
and eroded. Usually the whole vein as far as the liver is affected, and there 
may be hepatitis ; Wiederhofer found Glisson's capsule and the portal vein 
both involved. Peritonitis and intense jaundice are both common. The 
etiology of the disease is the same as that of arteritis. The symptoms of 
phlebitis are fever, icterus, altered respiration, inspiration being short, ex- 
piration prolonged, while the breathing is shallow, frequent, and entirely 
thoracic ; the upper part of the abdomen is tumid, and there is local tender- 
ness, the knees are drawn up, and the child is restless. It is difficult to dia- 
gnose phlebitis from arteritis ; the intense icterus in the former is the most 
characteristic feature. The disease lasts only a few days, and is always fatal 
from general sepsis. The treatment of both arteritis and phlebitis consists 
in the application of salicylic acid or other antiseptic and the use of stimulants 
and free nourishment, together with careful cleanliness. 

These diseases appear to be almost unknown in this country at the pre- 
sent day, judging from the absence of any literature, but they are likely to be 
met with in dirty quarters of large towns. 

Umbilical Haemorrhage is to be looked upon as a symptom rather than 
a disease in itself ; it is met with in the shape of bleeding from the umbilical 
vessels themselves, and as a general oozing from the raw navel surface. 

Bleeding from the vessels may occur from slipping or imperfect tying of 
the ligature round the cord ; as, for instance, when a thin ligature cuts into the 
vessels. Bleeding, of course, by no means necessarily follows slipping of the 
ligature, or even failure to tie the cord at all. The aspirating action of breath- 
ing prevents any haemorrhage in most instances, and this is supplemented 
by the contraction of the vessels after birth. 

Asphyxia may, however, produce some escape of blood as the vascular 
pressure rises in slight degrees of suffocation ; in other instances deficient 
muscular contraction appears to be the cause, hence bleeding is most common 
in premature children who have been asphyxiated or whose lungs have not ex- 
panded. If it arises from imperfect muscular contraction it may occur some 
hours after birth (Hofmann). As the vessels begin to contract at the cord, 
and the obliteration extends towards the hypogastrium, there is more risk of 
bleeding if the cord is cut very short. So, too, drying up of the cord tends 
to obliterate the vessels, while gangrene and swelling tend to prevent their 
closure. Bleeding may also occur later from rough handling of the navel 
and separation of the scab. All danger from this form of haemorrhage may be 
prevented by tying the cord firmly with a broad ligature not too near the 
abdominal wall ; should bleeding occur, pressure or the application of astrin- 
gent powders, a fresh ligature or acupressure will arrest it. 

Idiopathic, or spontaneous bleeding so called, is a very rare occurrence, 
and its etiology is obscure. Grandidier collected twenty-two cases from 
various sources. The bleeding usually occurs about the fifth day, just after 
or more rarely before the cord comes away, 1 the blood trickles from the 
surface of the umbilicus, and not from any distinct vessel ; the oozing may 
be continuous or intermittent. The subjects of the affection are generally 
1 ' It may, however, come on In the third week.' — Minot, 

D 



34 The Diseases Incident to Birth 

healthy full-time children ; there is often, however, slight icterus ; in other 
cases there is some intestinal disturbance, vomiting, colic, &c, with deep 
icterus, cyanosis, and drowsiness before the bleeding occurs ; in any case 
these symptoms appear soon afterwards. Bleeding not seldom comes on 
from the stomach or intestines, or there may be general purpura, and some- 
times there is oedema of the hands and feet together with the umbilical 
haemorrhage. 

The great difficulty or impossibility of stopping the flow is characteristic 
of the condition. Most of the cases die before the second week ; the 
mortality is put down as 83 per cent. The infant usually dies comatose, less 
often in convulsions. 

Umbilical haemorrhage is a symptom of several diseases ; probably in some 
cases, as we have already pointed out, it is due to haemophilia or syphilis. 
Privation, drink, and other depressing causes acting upon the mother are 
also assigned as reasons for it. Septicaemia and ' fatty degeneration of the 
newly born ' are causes that have been established by post-mortem evidence. 
The blood in these children does not clot readily. It is said to be a com- 
moner disease in America than elsewhere. 

Pressure by various means, such as pads, filling the navel with plaster of 
Paris, underpinning, &c, may be tried as means of treatment with some hope 
of success ; caustics and astringents, such as perchloride of iron, do not 
appear to be of much use ; the actual cautery has succeeded. Idiopathic 
bleeding is very rarely met with. Fiirth has, however, collected records of 
some cases; 1 it is sometimes epidemic. Weiss had 31 cases out of 742 
children in one year at Prague. 2 

For other morbid conditions of the umbilicus, see ' Deformities of the 
Umbilicus.' 

Tetanus Uascentium. — This disease is almost unknown in this country 
at the present day, although in past times, when less attention was paid to 
general hygiene in lying-in hospitals, it was common, and sometimes was 
the largest factor in infant mortality ; it was also frequent at one time among 
the negro population in America. The disease is identical with the wound 
tetanus of adults, and is caused by inoculation of the navel with the tetanus 
bacillus. This bacillus, as shown by Nicolaier, is constantly present in the 
superficial layers of the earth, and it gains entrance to the infant's body by 
dirty dressings applied to the navel. The bacillus multiplies in the neigh- 
bourhood of the navel, and a strychnine-like poison is absorbed, which 
gives rise to the muscular spasms. The bacilli may be detected in the pus 
of the navel wound, and if the pus be injected into mice they die with 
tetanic symptoms. (Rosenbach, Peiper.) Tetanus (' nine-day fits ') usually 
appears in the first two weeks of life, most commonly from the third to 
the tenth day, the limits, according to West, being from the fifteenth hour 
to the fifteenth day. The symptoms are usually acute, the earliest being 
inability to suck from spasm of the facial and jaw muscles (trismus) ; general 
contractions, however, soon occur, the spasms are continuous, but increase 
in violence at intervals ; in most cases there is no complete relaxation. The 

1 Arch. f. Kinderh. Band v. p. 305. 

2 For further details, vide a paper by Dr. Francis Minot in the American Jour, of 
Med. Sci. Oct. 1852. 



Tetanus Nascentium — Sclerema Neonatorum 35 

child often utters a peculiar whining cry, and there is well-marked risus 
sardonicus ; the maximum rigidity is generally reached in twelve hours, and 
the child dies in a fit or becomes comatose. 

The spasms are increased by any exposure to cold and by noise ; emacia- 
tion is very rapid, and there is often jaundice. Death usually occurs in one 
or two days ; in rare cases the disease is chronic. Hartigan says the chronic 
form begins with dysentery and coldness and pallor of the skin ; hence it has 
been called 'white lockjaw.' It is attended by wasting and twitchings, and 
was described by Marion Sims as 'Trismoid.' Unlike the acute form, which 
always occurs within the first month of life, the chronic variety may appear 
at any time within six months, and may be a sequel of the acute. 

The disease is readily recognised by the spasms and general rigidity. 

The preventive treatment consists in the most rigid cleanliness in dress- 
ing the navel and the removal of insanitary conditions. Opium, chloral, 
bromide of potassium, cannabis indica, belladonna, and other drugs have 
been occasionally successful ; warm baths sometimes relieve the spasms, and 
spinal icebags are worth a trial ; anaesthetics, such as ether and chloroform, 
are useful to relieve pain and allow the child to be fed, but none of these 
remedies have given any constant good result. Further details of the disease 
and references will be found in the works of Bouchut, Meigs and Pepper, 
Peiper, 1 Baginsky. 2 

Sclerema Neonatorum. — This rare disease is practically unknown outside 
foundling asylums and lying-in institutions, and is by no means common 
under any circumstances. The chief characteristics of the disease consist 
in an induration of the skin and subcutaneous tissues, and marked wasting, 
with an abnormally low temperature. The infants at birth may present 
no abnormality, and in some cases at least are plump and healthy-looking ; 
within a few days of their birth they begin to waste, the temperature 
becomes abnormally low, 83 to 86° F. in the rectum, and the integuments 
become hard and rigid ; the change usually begins in the lower extremities 
and spreads upwards, and involves the trunk, upper extremities, and face. 
In typical instances the skin is of a dirty yellow colour, its surface is hard 
and does not pit, and it cannot be raised from the subcutaneous tissues. The 
surface of the body has a cold feel almost like stone. In some described cases 
the rigidity of skin has been so great that the infant could be lifted by the 
head and heels like a rigid body. On account of the rigidity of the skin of the 
face, sucking is performed with difficulty, and the infant has to be fed with a 
spoon. The prognosis is bad, as such infants almost invariably die in a few 
days. In a typical case investigated by Dr. W. P. Northrup, of New York, 
the microscopical examination of the skin showed nothing abnormal. In a 
case of Dr. J. W. Ballantyne's there was an increase in the number and size 
of the connective-tissue bundles and an atrophy of the adipose tissue. 
Langer attributes the rigidity of the integuments to solidification of the fatty 
tissues, in consequence of the abnormally low temperature. In one case, 
however, reported by Dr. A. G. Bans, which he believes to have been of 
this nature, the infant, which was a month old when seen by him, made a 
good recovery. In this case the skin over the buttocks and thighs was hard 

1 Deutsches ArchivfUr klinische Medicin, Bd. xlvii. 11. 1 u. 2, 
8 Berliner klinische Wochenschrift, "So. 7, 1891. 

n a 



36 The Diseases Incident to Birth 

and rigid, and could not be raised from the deeper tissues. But it appears 
to have been red and shiny, and without the cold feel so typical of the 
ordinary cases of sclerema. The pathology of these cases is ill understood. 
It has been suggested with much plausibility that they are akin to myxcedema. 
YVe have seen a similar case in a girl two weeks old, in which the tissues of 
the back of the trunk, arms and legs were much indurated, red and shiny. 
They were too hard to pit with the finger. We think that this case, as also 
Dr. Barrs', were not identical in nature with those described as sclerema. 
We unfortunately lost sight of our case ; the infant was apparently healthy 
and thriving. 

(Edema Neonatorum. — Weakly, especially premature, infants are apt to 
be cedematous at birth, or become so soon after. An cedematous condition 
of the skin and subcutaneous tissues differs from sclerema in that the former 
readily pits beneath the finger, and the skin is more or less smooth and 
shiny. It is obvious that oedema may be present in many different condi- 
tions, and it does not in itself constitute a disease. 

Gonorrhoea! Ophthalmia. — Though hardly within the scope of this work, 
mention ought perhaps to be made of the danger to the infant of infection 
by gonorrhceal discharges from its mother at birth or shortly after. The 
most common affection is that of the eyes, in which a virulent purulent 
ophthalmia is produced. The inflammation rapidly spreads to the eyelids, 
and involves the cornea, speedily causing opacity, and if allowed to run its 
course unchecked ending in perforation of the cornea, with escape of the 
contents of the globe and complete shrinking of the eyeball. Many cases 
of total blindness in children are due to this cause. In any case where there 
is a suspicion of vaginal discharge from the mother, an antiseptic douche 
should be carefully used before the birth of the child, and immediately after 
it is born the child's eyes should be examined and carefully washed out 
with a solution of perchloride of mercury (1-4,000), followed by a douche of 
boric acid lotion. At the least sign of any inflammation the eyes should be 
washed with a solution of sulphate of zinc (2 grains-^j), and unless the 
mischief -is at once checked a solution of nitrate of silver (10 grains-^j) should 
be employed once a day, washing out again with a solution of salt directly 
after to prevent too powerful action of the silver. The eyes should be bathed 
every hour day and night with a lotion of boric acid, and the silver repeated 
if necessary. It is only by such means that the eyes can be saved in severe 
cases. The utmost care must of course be taken to use all applications 
thoroughly and get rid of every particle of discharge, as well as to avoid 
subsequent reinfection. For infantile gonorrhceal rheumatism, vide chapter 
on ' Diseases of the Joints.' 



37 



CHAPTER III 

THE HYGIENE AND DIET OF INFANTS AND CHILDREN 

Newly Born Infants. — One of the first cares of the nurse after the navel 
has been properly attended to should be to direct her attention to the 
infant's eyes, carefully wiping away, by means of a soft rag, any mucus or 
vaginal discharge which may adhere, and thoroughly cleansing the eyelids 
with warm water. This is a matter of much importance and should never 
be neglected, for if conjunctivitis or a purulent ophthalmia be set up, much 
trouble may ensue and some time elapse before a healthy state is again 
attained, and the risk of corneal opacities and consequent loss of sight is by 
no means small. The temperature of the room in which mother and infant 
are should be maintained, at least in winter, at 65 , and means be taken to 
thoroughly ventilate it without producing draughts. 

In giving the infant its first bath — necessary on account of the slimy 
whitish secretion with which the infant is covered — care should be taken 
that it is done before a good fire, and that the water of the bath is not too 
warm ; the temperature should not exceed 95 ; the infant's skin is exceedingly 
tender, and hot baths are liable to give rise to urticaria or even pemphigus. 
The infant is usually given a daily bath in order to secure cleanliness, 
especially about the genital organs and buttocks, which are fouled by con- 
tact with the diapers, and nothing is more likely to give rise to excoriations 
and intertrigo than the skin being smeared with decomposing urine. Some 
infants' skins are far more tender than others and liable to eczema, and require 
constant care to avoid irritation. For such, care should be taken in the 
selection of a soap which is free from excess of alkali, such as the best class 
of pure Castile soaps, or Unna's 'over fatty' soap, all excess being removed in 
the bath. The skin should be carefully dried with a soft towel, and some fine 
dusting powder applied to the folds of the groin and buttocks. This may 
consist of finely powdered maize or oatmeal mixed with 2 per cent. oi 
salicylic acid, 5 per cent, of boracic acid or thymol, to prevent any tendency 
to decomposition. Pure boracic acid, as in the 'Sanitary rose powder,' 
answers very well, and as it is soluble in water is easily removed by washing. 
The diapers should be of a soft and absorbent material ; at least a dozen 
should be provided for use during the twenty-four hours. 

In the first few days, before the cord has separated, a flannel binder 
loosely applied is necessary to protect it and keep the dressings in position, 
but afterwards all binders should be avoided ; at least, nothing tight should 



38 The Hygiene and Diet of Infants and Children 

be applied round the abdomen which would cause discomfort to the child by- 
compressing the abdominal viscera. The cord may be dressed with a pad 
of wood wool wadding or Gamgee tissue. 

It is hardly needful to say that a cot should be provided for the infant 
with a firm mattress protected by a waterproof covering, and under no 
circumstances whatever should the infant be allowed to sleep in bed with its 
parents or nurse ; fatal accidents through suffocation of the infant beneath 
the bedclothes are constantly occurring in consequence of the mother falling 
asleep with her infant in bed with her. 

Clothing-. — All the clothing should be loose, and as far as possible con- 
sist of woven or knitted woollen material, but it will have to be protected 
from being fouled by the discharges by means of napkins, which may be made 
of ' swansdown ; or similar material. The common tendency is to load the 
chest and body with too great an amount of clothes and to leave the legs 
and thighs too much exposed. For the latter, long loosely fitting woollen 
drawers coming to the waist should be used, carefully protected by the diapers 
from being wetted. 

Infant Feeding- at the Breast. — The natural food of an infant is the milk 
from the breast of its mother, no kind of food being thought of for the first 
eight or nine months of its life. The mother's health may of course sooner 
or later interfere with the performance of this duty to her infant, but it is of 
great importance that it should be attempted, if for only a few weeks or 
months, for to undertake the artificial feeding of an infant from the first is to 
expose it to serious risk. 

The infant should be put to the breast a few hours after birth, after the 
mother has somewhat recovered from the pains and fatigue of labour, and 
has had some sleep. It is of much importance that both mother and infant 
should get as much rest at night as possible, and if the infant frequently 
wakes crying, every means should be taken to hush it off to sleep again, 
and for this a little sweetened water or barley water may be used. It is not 
unlikely that for the first few days, especially in primipara;, the supply of 
milk will be scanty and the infant will hardly get its full supply ; but this is 
a matter of little importance, and it is in many respects well not to overload 
the stomach at first, but to give it an opportunity of gradually accustoming" 
itself to its new function. 

From the very first it is of importance to accustom both infant and 
mother to regular times for feeding. At first, every two hours during the 
daytime will be quite often enough for an infant of average weight and 
strength. A longer interval may be taken in the night, so as to give the 
mother as long a sleep as possible ; ten feedings in the twenty-four hours 
will be sufficient. A strong newly born infant empties the breasts in about 
fifteen minutes, and, during this time, takes from 1 to i| oz. of milk, the 
total amount taken in the twenty-four hours during the first week being 10 
to 12 oz. The infant's stomach, at this period, being only capable of hold- 
ing about 1^ oz. (see fig. 1) without marked distension, too rapid filling of 
the stomach with fluid is very likely to give rise to vomiting. It is there- 
fore of importance for the mother to feed the infant slowly, extending the 
time to fifteen or twenty minutes. We must not forget that probably rapid 
absorption is going on during the time the infant is being fed, in strong and 



Infant Feeding at the Breast 39 

vigorous children, so that it may often happen that such will take more than 
the above amounts without injury. 

The infant's stomach rapidly enlarges, and the secretion of milk increases 
as time goes on ; so that, after the first week or two, eight nursings in the 
twenty-four hours — that is, every two and a half hours during the day, and 
a longer interval at night — will be often enough. From the beginning of the 
third month till the end of lactation, every three hours will be often enough, 
some 3 to 6 oz. being taken at a time, and some 20 to 40 oz. in the twenty- 
four hours. Six to seven nursings in the twenty-four hours will be sufficient. 

Too frequent nursing is bad for the infant, inasmuch as an overworked 
stomach cannot properly perform its functions, and a dyspepsia is only too 
likely to result ; the mother's breasts require an interval of rest, for, if too 
frequently drawn, the milk is apt to be unequal in composition, too watery 
after a long, and too rich and concentrated after a short interval. 

During the whole time the infant is being nursed the health of the mother 
will necessarily be a question of the greatest importance, as it is impossible 
for a weakly mother, or one in ill-health, to give good milk. The food which 
she takes and the life which she leads are all-important. Anything causing 
indigestion in the mother will be extremely likely to affect the breast milk 
and disturb the infant's digestive organs. 

Various drugs, such as morphia and Epsom salts, when taken by the 
mother, are excreted in the milk, and may of course affect the infant. Any 
violent emotion, such as a great sorrow or any prolonged anxiety suffered by 
the mother, is very likely to alter the quality of the milk, and the infant con- 
sequently suffers. Indeed, under these circumstances, the milk may cease 
to be secreted, and the infant have to be artificially fed. The mother's diet 
should consist largely of milk, porridge, soups, potatoes, fish, and light pud- 
dings, while beef, mutton, and stewed fruit should be taken in moderation. 
She should avoid all highly seasoned foods, and those difficult to digest, such 
as pastry, raw fruit, uncooked vegetables. Alcoholic liquors are unnecessary, 
and tea and coffee should be taken in moderation. Exercise in the open air 
is of the greatest importance. 

According to Forster, increasing the amount of fat taken in food does 
not increase the amount of fatty matters in the milk secreted, while proteids 
taken increase the fat in milk. For the mother or wet nurse excessive 
quantities of food should certainly be avoided, and, especially if she is much 
confined to the house, much meat should not be taken. 

The milk of the first few days differs from normal milk in that it has a 
higher specific gravity, contains more salts, less sugar, and is coagulated by 
means of heat in consequence of the large amount of albumen which it 
contains. This colostrum is apt to set up more or less dyspepsia or diarrhoea. 
In a few days the excessive quantity of albumen disappears and the milk 
becomes normal. The changes which occur in the quality of the milk during 
the lactation period depend very largely of course on the health oi the 
mother. During the later months of lactation the milk becomes poorer and 
more watery, with a tendency, according to Pfeiffer, to a diminution ot the 
proteids and an increase of the sugar. It must be borne in mind how com- 
pletely the secretion of the milk is under the influence of the nei\ OUS SJ stem, 
and, moreover, it varies from time to time from various causes ; and n 



4-0 The Hygiene and Diet of Infants and Children 

or less caution must be observed in drawing conclusions as to the effect of 
any one cause on the quality of the milk. 

The occurrence of menstruation in a nursing mother or wet nurse is apt 
in some way or other to alter the secretion of the milk, and the infant, in 
consequence, may suffer from colic, flatulence, or diarrhoea. In many cases 
the infant does not appear to suffer at all, while in exceptional cases the 
intestinal disturbance and loss of flesh are so great that the question of wean- 
ing may have to be entertained. It may happen that the infant may suffer 
a good deal at one period and not at the next or succeeding ones. The 
chemical changes which occur during menstruation have been investigated 
by several observers, but no constant change has been found. In some 
cases the careful observations of Rotch have shown that the milk during 
this period is poorer in fat and richer in proteids, but it is tolerably certain 
that this is not universally the case. Monti found that menstruation exercised 
no constant change or influence on the specific gravity or the fatty elements 
though in some cases observed by him there was an increase in the quantity 
of fat during the period. ' 

As the result of numerous observations, Schlichter found that the casein 
and fat were slightly increased, and the proteids, sugar, and solids were 
decreased, during menstruation ; but as just as great changes were observed 
from time to time during the intervals between the periods, it is evident the 
changes noted during menstruation cannot be of importance. This author 
regards menstruation occurring before the sixth week as likely to affect the 
well-being of the infant by causing serious changes in the milk ; on the 
other hand, menstruation recurring at a later period is of comparatively 
small importance. 

Wet Nurses. — It not infrequently happens that, if an infant's life is to be 
saved, a wet nurse must be procured. It may happen that a weakly infant 
is deprived of its mother's milk, and a foster mother must be obtained if its 
life is to be saved. In some cases, perhaps, an attempt has been made to 
feed a young infant on some artificial food, various foods being tried, one 
after another, till severe convulsions or continuous diarrhoea warn the 
attendants that a return to the infant's natural food is the only possible 
resource left. Much has been written about the advantages and dis- 
advantages of a wet nurse. We may say at once that, in our opinion, there is 
not the least doubt that no artificial food yet devised can compare with or 
form a substitute for the milk of a healthy woman. To attempt to bring up 
a weakly infant from the first on artificial food is to expose it to far more 
serious risks than if it is provided with a healthy wet nurse. Unfortunately 
in this country wet nurses are difficult to obtain, and when obtained are not 
always easy to manage in the household. At the same time, we are inclined 
to think that the character of wet nurses as a class has often been painted in 
too black colours ; certainly we have known many who have done their duty 
to their foster infants in a most worthy and exemplary manner. A difficulty 
often is presented with regard to the nurse's own child ; it is put out to 
nurse, and is deprived not only of its mother's milk, but also of its mother's 
care, and is only too likely to go the way that so many ' out-to-nurse ' babies 
have gone before. In large cities wet nurses are usually obtained at the 
workhouses, where many women go to be confined, and are often glad to 



Wet Nurses — Weaning 41 

escape from the discipline of the workhouse, and to obtain a situation in a 
private family at good wages. 

A wet nurse should not be above thirty-five or below twenty-one 
years of age ; very young wet nurses are especially to be avoided, on 
account of their inexperience and the difficulty in managing them. It is 
better for the nurse's infant to be a month or so older than the infant to be 
nursed. Great disparity of age is an objection, as a nurse who has been 
confined five or six months before is not likely to make a good nurse for a 
newly born infant, at least not for the whole time that the infant has to be 
nursed ; but such a nurse may be employed temporarily in the absence of a 
more suitable one. A disparity of two or three months is no objection, pro- 
vided the nurse is suitable in other ways. A medical examination of the 
nurse should always be made — at least, the medical attendant should satisfy 
himself that both the nurse and her infant are free from disease. There is 
one advantage in the nurse's infant being two or three months old, and that is 
that time would have been afforded for any syphilitic rash to make its appear- 
ance on the infant, and the infant if strong and vigorous is reliable evidence of 
the good quality of the milk. If possible, an analysis of her milk should be 
made upon several occasions, especially with regard to the amount of fat 
present in the milk. But, in spite of all precautions, we must be prepared 
at times to find that the milk of a wet nurse who in every way appears 
suitable does not agree with the infant, and the only resource is to try another. 
Great pains must be taken in the dieting of the nurse, errors being most fre- 
quent in the direction of overfeeding with too little exercise. Meat once a 
day is enough, beer and porter are best avoided, and exercise in the open 
air must be insisted on. 

No infant suffering from hereditary syphilis should be wet-nursed, on 
account of the risk of its infecting its foster mother. 

Weaning-. — The length of time during which the infant takes its sole 
nourishment from its mother's breast depends upon a variety of circum- 
stances. When the mother remains strong and healthy and has a sufficient 
supply, the time may be extended to eight or nine months, or even more. 
Among the working classes the time is often extended much longer than 
this. Infants Avho are over-nursed are apt to be fat, but are not necessarily 
strong — indeed, they often appear rickety in a minor degree. In a case re- 
cently coming under our notice, the mother nursed her infant entirely at the 
breast for seventeen months. The child weighed twenty pounds, it showed 
signs of rickets, the epiphyses being moderately enlarged and the ribs 
beaded. An examination of the mother's milk, which was plentiful, showed 
it was poor — the amount of fat (average of three samples) 17 per cent.; the 
specific gravity was 1031. 

Whenever weaning takes place it is wise to do it gradually, in the first 
place substituting the bottle for the breast once or twice in the twenty-four 
hours, and carefully watching the result before attempting more than this. 
Gradually artificial feeding may be made to take the place ot the breast en- 
tirely. It is well to avoid the hottest weather for this change on account of 
the risks of diarrhoea at this time. 

At any time during the period of lactation it may be necessary, on 
account of the mother's health, to supplement musing with other food, or to 



42 The Hygiene and Diet of Infants and Children 

give up nursing altogether. The question of whether to give up nursing or 
not is often a difficult one to decide. If the mother is suffering from any 
organic disease, there cannot be any doubt as to giving up nursing both for 
her own sake and that of the infant. It may happen that the breast milk 
entirely goes, and either a wet nurse must be obtained or artificial food be 
substituted ; in other cases the decision is much more difficult ; the infant does 
not appear to thrive, and the fault may be in the quality of the mother's milk. 

Much useful information may be gained by weighing the infant every 
week ; a regular gain of 5 to 6 ounces a week during the first three or four 
and 3 to 4 ounces from the third to the sixth month will indicate that the 
infant is thriving in spite of some minor troubles it may be subject to. It 
must be remembered, however, that the infant may put on fat without a 
corresponding development in the other tissues. One of Salter's family 
spring balances with oblong pan capable of weighing 25 lbs. by 1 ounce will 
answer very well for the purpose. 

Valuable information may be obtained by an examination of the breast 
milk ; unfortunately, no mere inspection or microscopical examination is of 
any use : an analysis must be made by a competent chemist by ordinary 
methods, or approximate results may be attained by the methods referred to 
below. Moreover, it will be necessary to have several analyses made before 
coming to any definite conclusion. Care should be exercised to see that the 
milk taken for analysis is the middle portion : that is, the infant should be 
put to the breast for five minutes or more, and then i-i oz. drawn from the 
same breast by means of a breast pump. This will give a fair sample of 
the milk. The two most important constituents, as Rotch points out, are the 
amount of fat and the amount of proteids present. A low proportion of fat 
and a high proportion of proteids indicate a bad milk. 

The following examples, taken from Rotch, represent examples of 
(I.) normal milk, (II.) poor milk, (III.) over-rich milk, (IV.) bad milk : 





I- 


II. 

I-50 
240 
4'00 
- 09 


III. 


IV. 

o-8o 
4-50 
5-00 
0-09 


Fat 

Proteids .... 
Lactose .... 
Ash 

Total solids 

Water .... 


4 
1-2 

7 

0'2 


5-10 

3'5o 
7-50 
0-25 


12-13 

88-87 


7'99 
92-OI 

ioo-oo 


1635 
83-65 


10-39 
89-61 


I OO- I OO 


ioo-co 


IOO'CO 



Recently Monti has published the results of his examination of the milk 
of 300 women by taking the specific gravity, reaction, and estimating the fat 
by means of Marchand's lactobutyrometer. 1 

Emmet Holt has suggested the employment of a creamometer and taking 

1 Archivfur Kinderheilktuide, Band xiii. page 1. We have employed this apparatus 

on many occasions, both for cow's and also human milk, and though we cannot say it 

is satisfactory in every respect, yet, if care be used, it will give the percentage of fat in milk 

fairly correctly. 



Artificial Feeding — Cow's Milk 43 

the specific gravity, as guides in forming an opinion as to the quality of the 
milk. (For other methods see Appendix.) 



Artificial Feedings 

The most convenient substitute for human milk is the milk of the cow. 
The milk of some other animals, such as the goat, ass, mare, has been used 
with more or less advantage, but cow's milk is likely to remain the all but 
universal substitute. Goat's milk has one or two practical advantages ; in 
the first place, the goat is said not to suffer from tuberculosis, while the cow 
is known to be very liable to this disease ; and in the second place, for a 
family in the country having their own grass plot, it' may be often very con- 
venient to purchase a milch goat and fodder it at home. A milch goat is of 
course much cheaper than a cow, and can be kept at practically no expense. 
The chemical differences between the milk of the cow and that of the goat 
are not great, and there is no advantage except that already mentioned in 
substituting goat's milk for cow's milk. 

The milk of the ass much more nearly resembles human milk than either 
the milk of the cow or goat. Unfortunately asses' milk is difficult to obtain 
in this country, and is also costly. 

Cow's Milk. — The milk of the cow has been studied more closely than 
the milk of any other animal, on account of its great importance to the 
community as an article of commerce. As a food its importance is derived 
from the fact that it supplies in due proportion proteids, carbo-hydrates, 
hydro-carbons, salts and water, while it contains no waste products, and, 
moreover, it is digested with comparative ease. It requires when fresh no 
preparation to render it fit for consumption. 

The richness of milk is influenced in various ways — the materials with 
which the cows are fed, the length of time during which they have been in 
milk, and also by the breed. The milk supplied at our doors, it is needless 
to say, varies with the honesty of the purveyor and the cleanliness observed 
in its collection and transit. 

We give here three different analyses of cow's milk : (I) a good average 
specimen according to Leeds ; (II) a pure milk according to Langlois ; 
(III) an average specimen as supplied by the milkmen of Paris (Langlois) : 



Specific gravity .... 
Vol. of cream .... 


I. 

10297 

375 
4-42 
376 

•68 

12-61 


Fat 

Lactose ..... 

Proteids 

Ash 

Total solids .... 



II. 


III. 


1 03 1 7 


*°33 


10 


77 


4 


3\U 


5 


4'02 


.V4 


3 '4 


•6 


'57 


13-0 


12-23 



The rat of milk consists principally of margarine and oleine ; it is 
present in milk as minute globules, which on standing rise to the surface in 



44 The Hygiene and Diet of Infants and Children 

the form of cream. A microscopical examination of a drop of milk displays 
these minute globules of fat, and also colostric corpuscles and fatty 
epithelial cells if the animal has recently calved. According to some the 
fatty globules are surrounded by an albuminous envelope : others believe 
milk to be really an emulsion, in which the fatty particles are held in 
suspension by the albumen and caseinogen in the milk. The fat can be 
extracted by shaking with ether, after the addition of a drop or two of a 
solution of caustic potash. If milk be long heated at ioo c C. or at a higher 
temperature, the emulsion is in part interfered with, and globules of butter 
oil will rise to the top if the milk is warmed ; a microscopical examination 
of such milk will show the fatty globules have in part run together. 

The Iiactose is the member of the carbo-hydrate group present in milk, 
and is destined to be in part converted into lactic acid in the stomach, 
whilst the rest is converted into glucose in the intestines and in this state 
enters the blood of the portal vein. The former process is the result of the 
action of the ' lactic acid bacillus : : but there are numerous varieties of 
micro-organisms which are capable of converting lactose into lactic acid. 
Lactic acid appears to be always present in normal digestion in the stomach, 
but in some forms of dyspepsia excessive quantities are formed, so that some 
infants who are suffering from chronic dyspepsia have a strong ' sour milk : 
odour. Possibly this rancid smell may be due in part to butyric acid. Lactic 
acid may be decomposed into alcohol and carbonic acid, and also into butyric 
acid and carbonic acid. The latter two processes probably only take place in 
abnormal digestion. 

The Proteids of milk are two in number — caseinogen and lactalbumen 
(Halliburton;. In cow : s milk the former is present in much larger quantities 
than the latter, the reverse holding good in woman's and asses' milk. 
Caseinogen is precipitated by acetic acid or by saturating with a neutral salt 
such as sulphate of magnesia ; lactalbumen is coagulated on boiling. 
Lactalbumen closely resembles serum albumen, but it coagulates at a some- 
what higher temperature. ~~ z C. Halliburton . It only slowly coagulates at 
this temperature, and even at a higher temperature some time is required to 
fully coagulate it. 

If rennet be added to cow's milk the caseinogen is decomposed into casein 
or curd of milk, which is precipitated in dense flakes, and a second proteid, 
the 'whey proteid'" which remains in solution. The presence of lime salts 
is necessary for this change to take place Hammarsten). 

'Whey proteid' is not precipitated by heat. It is probably this 'whey 
proteid : which sometimes appears as small curds in the stools of newly born 
children and others who are being fed exclusively on whey. 

The curd of cows milk forms a dense heavy lumpy precipitate in the 
stomach, differing very markedly from the soft flocculent precipitate from 
woman's milk. According to Langlois the ferment in the stomach precipi- 
tates the curd but does not dissolve it. the curd passing unchanged into the 
intestines, where it is converted into peptone by the action of the pancreatic 
juice ; this view, however, is not universally accepted. Various bacteria have 
the power of converting casein into peptone and ptomaines. 

The Salts of milk consist of potash, lime, and soda in combination with 
phosphoric acid and chlorine. 



Woman s Milk 45 

We may know that the milk supplied to our houses is unadulterated, 
having been neither watered nor ' let down' by admixture with skimmed 
milk, but for the most part we have to take in good faith that the cows are 
healthy and carefully fed, and that the most scrupulous care has been 
observed with regard to cleanliness in the milking of the cows and in the 
conveyance and storage of the milk. Unfortunately, our confidence is at 
times misplaced. We find that in the winter time the cows are fed with the 
idea of forcing them to yield the greatest quantity of milk, without any regard 
to its suitability for the food of infants ; turnips and brewer's grains being 
used largely instead of hay, maize, or other dry fodder. In the summer time 
the cows graze in fields which are perhaps watered by town sewage, in 
which the cows may lie down and become befouled. The sheds or byres 
may be badly ventilated and much filth may be allowed to accumulate in them, 
and the cows may become besmirched with excrement. Small wonder is it 
that the milk supplied contains hair, fragments of excrement, bits of hay and 
straw, sand and grit, and as a consequence of these contaminations, if kept 
for any time, swarms with organisms. 

Great care should be taken to select a milkman who takes a pride in the 
foddering and cleanliness of his cows, and will take some trouble to deliver 
the milk as quickly as possible after milking. It is a good plan to have a 
private milk can, and to get the farmer to milk his cow directly into this can 
and to deliver at once. 

Woman's XVXilk. — The following figures, according to Leeds, represent the 
principal differences between cow's and woman's milk : 







Sound dairy rmlk 


Average woman's milk 


Reaction 




. acid 


alkaline 


Specific grav 


ty 


. 1029 


1 03 1 


Fat 




• 375 


4'i3 


Lactose . 




• 4-42 


7 


Proteids 




. 376 


2 


Ash 




•68 


'2 


Bacteria 




numerous 


absent 



We have taken the analyses of Professor Leeds of woman's milk as being 
the average of a large number of specimens, but the variations in different 
samples is very considerable. The analyses given by different authorities 
also differ largely. Dr. Luff's analyses of twelve samples made for Dr. 
Cheadle show on an average a less rich milk than the results of Professor 
Leeds' analyses given above — viz. fat, 2-41 ; lactose, 6*39; proteids, 2*35 ; 
ash, -34. 

The principal points to be noted are the following: ^0 The excess o( 
proteids in cow's milk, and the excess of curd (caseinogen) over lactalbumen 
as compared with woman's milk. According to Hirt, the amount oi curd in 
cow's milk is 3 per cent, (lactalbumen 7.5 per cent.), in woman's milk it is 
only "63 per cent, (lactalbumen 1*5 per cent.), so thai the amount of curd i> 
nearly five times as great in the former as in the latter. (2) Smaller quantity 
of lactose in cow's milk. (3) The tat is (?) slightly higher in woman's milk. 
(4) The ash is greater in cow's milk. (5) By the time the cow's milk teaches 



46 The Hygiene and Diet of Infants and Children 

the consumer it is slightly acid and contains numerous bacteria, while 
woman's milk is supplied direct to the infant, and is alkaline and sterile. 

In substituting cow's milk for human milk, we necessarily endeavour to 
imitate the latter as much as possible. The great difficulty to be overcome 
is the large quantity and solidity of the curd which is thrown down in cow's 
milk when the latter comes in contact with the walls of the infant's stomach. 
Woman's milk curdles in soft flakes, which hardly offer any resistance when 
pressed between the finger and thumb, while the curd of cow's milk, es- 
pecially if the curdling has been rapid, consists of firm cheesy lumps. The 
digestive juices of the infant's stomach and intestines are unable to dissolve 
these lumps, and, if not vomited, they partially decompose under the influence 
of the bacteria they contain, gases and ptomaines are formed, and much 
discomfort and perhaps diarrhoea or convulsions take place before the de- 
composing curd is passed in the stools. Anyone who has had an opportunity 
of carefully watching the effects of cow's milk when taken by an infant a 
few days old, and noted the effect if the milk of a wet nurse is substituted 
for cow's milk, will see at once the difference in the quality of the stools, 
and the immediate cessation of the discomfort and indigestion which the 
infant is certain to have suffered when taking the cow's milk. The difficulty 
with regard to the curd can partly be got over by diluting and peptonising 
or adding malt extract, but no method has been discovered by which cow's 
milk can be rendered as digestible and nutritive as woman's milk. The 
curd thrown down from condensed milk, or milk which has been desiccated, 
appears to digest more readily and with less discomfort than the curd of 
fresh cow's milk. 

Cream Mixture. — While the readiest way to prepare an infant's food 
from cow's milk is to dilute with water and add sugar, it is plain that the 
diluted milk will be deficient in fat, as compared with breast milk. To 
make good this fat, cream may be added. But here the practical difficulty 
which confronts us is the uncertainty of obtaining fresh cream of a definite 
strength. Cream which has been skimmed off milk after standing for 
twenty-four hours is too stale for use as infant's food, and much of the 
cream sold in bottles is by no means sterile and of very uncertain strength. 
We believe the best way to prepare an infant's food from cow's milk in the 
household so as to render it as near breast milk as possible is to adopt the 
following method, which is a modification of that suggested by Meigs. A 
pint or a pint and a half bottle such as the one in fig. 8 is filled to the upper 
mark with milk as soon as it arrives. A plug of pure cotton wool is placed 
in the neck, and the bottle is allowed to stand at the temperature of an 
ordinary sitting-room for two hours. By the end of that time a certain 
amount of cream will have risen to the top. The lower half is then syphoned 
off with a glass syphon, and replaced with an equal quantity of a seven- 
per-cent. solution of sugar of milk. 1 The milk in the bottle is then sterilised 
at 160 F. for twenty minutes in Hawksley's or a similarly constructed 
steriliser (see Appendix). The bottle is then cooled rapidly in running 
water and kept in as cool a place as possible. The food should be warmed up 

1 This may be made approximately by taking two measured ounces of milk-sugar and 
adding warm water to make fifteen ounces in all. 



Cream Mixture — Diluted Milk 



47 




15 oz- 



just before using ; all 'food warmers' which keep the food warm for some 
hours are on no account to be used. It is well to use the milk within twenty- 
four hours. 

Perhaps a simpler method than the above is to allow the milk to 
stand in a cylindrical tin with a small stopcock fitted to the bottom ; 
the lower half is drawn off, after standing for two 
hours, through the stopcock. If the milk supplied to 
the household be a good average one, containing, say, 
3-5 per cent, of fat, then the food as made above will be 
found to contain 2*6 to 3 per cent, of fat, 5 to 6 per cent, 
of sugar, and 17 to 2 per cent, of proteids. A twentieth 
of its volume of lime water may be placed in the bottle 
when the infant is fed. 

A more certain result can be obtained by the use of 
a centrifugal cream separator. This apparatus is now 
much employed by the better class of dairymen. A cer- 
tain quantity of milk is passed through the separator, 
the result being cream and separated milk, the latter con- 
taining only a very small percentage of fat. The whole Fig. 8. 
of the cream is mixed with half the separated milk, 
and an equal quantity of an 8 or 9 per cent, solution of sugar of milk is 
added. 

Some separators can be arranged to supply a mixture of the whole cream 
with half the separated milk, and if milk and water in equal quantities is 
supplied to the separator instead of pure milk the whole of the cream — 
that is, nearly all the fat in the milk, leaves the separator with one half 
of the milk and water, while the other half is very nearly sine fat. It is 
evident that the former will have all the fat, half the curd, half the sugar, 
and half the salts. Sugar can be added — either milk sugar or cane 
sugar. 

Both Biedert and Rotch have also strongly recommended mixtures con- 
taining cream, milk, lime water, and sugar. Rotch suggests the following 
mixture : 



Cream 
Milk 

Water 



ii ounce 
r ounce 
5 ounces 



Lime water 
Milk sugar 



\ ounce 
2 teaspoons 



Cream is mostly digested well by infants if the proportion of fat in the 
food is kept below 3 per cent, and too much food is not given to the 
infant. Food too rich in fat may give rise to vomiting and diarrhoea, and 
possibly gastric catarrh. 

Diluted iVEilk. — Undoubtedly the readiest way to prepare an infant's food 
is to dilute milk with water and lime water, and add sugar. That food so 
prepared is inferior to the foods in which cream forms the basis is e\ idem, 
yet it cannot be denied that very many children arc brought up on diluted 
cow's milk and appear to thrive on it. Many such children pass much curd 
in their stools without being the worse for it. The poorer classes cannot 
get fresh cream, or indeed any cream at all. and have from necessity to 
prepare their infants' food from milk. As we should naturally suppose, it is 



48 The Hygiene and Diet of Infants and CJiildren 



the newly born infants who are most intolerant of cow's milk, and great care 
is required in adapting the strength of the milk to the infant's condition. It 
is necessary at first to dilute cow's milk with two-thirds sugar water, 1 one- 
twentieth part consisting of added lime water, so as to secure that the food 
should be faintly alkaline. We should, however, much prefer to give a newly 
born baby whey and cream or diluted peptonised milk if it is necessary to 
feed it artificially. 

After the first three or four weeks, if the infant's digestion appears good, 
half milk and half sugar water'- may be given, (one-twentieth part being- 
lime water). From three months of age to six months, one-third part of 
sugar water should be added. 

Barley Water, Oatmeal "Water, &c. — For many years past it has been 
the practice to use certain thin gelatinous fluids, such as barley water, oat- 
meal water, arrowroot water, or fluids containing maltose and dextrin, to 
dilute milk with for infant feeding. All these fluids, except perhaps the last 
named, contain small quantities of starch. Now it is certain that the powers 
of young infants for converting starch into sugar are feeble, and if these 
fluids are used care should be taken in their preparation to avoid any quan- 
tity of starch being present. The saliva of infants three or four months old 
has undoubted powers of starch transformation, and apparently the pancreatic 
and intestinal juices have also, so that by the time this age is reached we 
have nothing to fear from thin starchy fluids. It has been claimed for these 
gelatinous fluids that when used to dilute milk they play a useful part in 
preventing the curd from running together into lumps during the time that 
coagulation is taking place. It is certainly difficult to demonstrate this in a 
test tube, but it is probable that any colloidal or gelatinous fluid interferes 
with the rapid diffusion of the acid and curdling ferment through the fluid, 
and consequently the curdling takes place slowly, and there is in consequence 
less tendency to the formation of lumps of curd. Neither starch nor maltose 
is present in the natural food of infants, yet experience teaches that the 
addition of a thin malted food or barley or oatmeal water has a considerable 
nutritive, value, and we entertain no doubt on this point. For infants below 
six months of age, we dilute milk more or less in order to reduce the amount 
of curd present ; in doing so we render the food poorer in hydrocarbons than 
mother's milk. This diluted milk is rendered more nutritive by the addition 
of malted starch, and this is, in some instances at least, more readily assimi- 
lated than milk diluted with water only. 

■Whey. — Whey is a useful substitute for mothers milk in those cases 
where for a few hours or for a day or two milk fails to appear in the breasts. 
Unboiled whey contains fat, lactalbumin, ' whey proteid,' lactose, and some 
of the salts of milk. Where a weak food is required whey often answers 
admirably, when made from fres/i milk. Some sugar of milk may be added. 
Care should be taken in preparing the whey to use rennet or an artificial 
curdling ■fluid free from an excess of salt, as brine is often used to prepare 
the artificial rennet. 

Peptonised Milk. — The predigestion of the curd, or rather the casein- 
ogen of cow's milk, is undoubtedly a useful resort in the artificial feeding of 
infants. It can be easily demonstrated that milk partially peptonised less 
1 5 per cent, solution of milk sugar. 2 7 per cent, solution of milk sugar. 






Peptonized Milk — Sterilisation 49 

readily curdles on the addition of rennet or acid, and that the curd thrown 
down is softer than that thrown down from fresh cow's milk. Clinical 
experience also testifies to its value, especially in infants with irritable 
stomachs or gastric catarrh. Some infants will, however, continue to pass 
curds in their stools while taking peptonised milk properly prepared, and at 
times it appears to disagree, especially when carelessly prepared. Infants will 
also often appear to thrive on it for awhile and become well nourished, but 
if it continues to be the sole food for many months together, they are apt to 
become anaemic, and suffer from various haemorrhages. (See Scurvy-rickets. ) 

Great care should be bestowed on its preparation, so that the digesting 
process may be carried far enough, but not too far. In the latter case a 
bitter taste becomes well marked, which is with difficulty covered. 

The best way to prepare this form of food is to utilise the cream mixture 
already referred to, and also the sterilising apparatus. A reliable peptonising 
powder containing pancreatine and soda may be added to the mixture when 
nicely warm (1 io° F.), and the temperature raised during the next ten minutes 
or quarter of an hour to 160 F., when the process is complete. Or the 
temperature may be carried to the boiling point. 

Peptonised milk food may be prepared from one of the well-known foods 
prepared by Benger & Co. or other reliable firms. 

Sterilisation. — Where milk can be obtained absolutely fresh and uncon- 
taminated from undoubtedly healthy cows, and is consumed at once, steri- 
lising processes are of course unnecessary, but only infants resident in the 
country, where cows are kept on the premises, can have these advantages. 
Cow's milk, as it is received by householders in towns, is usually many hours 
old before it is received, and it may be kept, or at least some portions of 
it, for twenty-four hours longer before the infant takes it. During this time 
the bacteria which it has received by means of various contaminations 
multiply enormously, especially in hot weather. Milk which is acid and 
'just on the turn' is, it is needless to say, quite unfit for infants' food. Many of 
the bacteria found in stale milk are probably harmless, or at any rate not 
actively mischievous ; others which may be present, especially the ' peptonis- 
ing bacteria,' are unquestionably deleterious, inasmuch as they form during 
their growth various animal poisons of the ptomaine type, which give rise 
when taken to acute diarrhoea or gastro-enteritis. 

Various pathogenic bacteria may be present in milk, either derived from a 
diseased cow, or from sewage or other contamination entering the milk. 
Tubercle bacilli may be derived from cows suffering from tuberculosis of the 
udder, and there can be no doubt that diphtheria, scarlet fever, typhoid fever, 
and foot and mouth disease may be spread though contaminated milk. Fortu- 
nately all these bacteria are destroyed at a temperature of boiling water; indeed, 
there is good evidence that they cannot withstand a temperature oi 70 C. if 
continued for half an hour. Of the saprophytic bacteria there are many 
varieties. There are the lactic acid group, and with these are the butyric 
acid producers. Others, which are much more important, are those which ^\o 
not act on the lactose, but if present in sufficient numbers peptonise the 
proteids, forming peptones and albumoses. Milk containing the latter it" it 
is at all stale given to mice or guinea pigs produces diarrhoea, while pure 
cultures quickly produce diarrhoea and death. 

t 



5<D The Hygiene and Diet of Infants and Children 

Sterilising for household purposes rests on a somewhat different footing 
than sterilising in large establishments where the milk has to keep for many 
months. The milk sterilised in the household has only to be kept for twenty- 
four hours or thereabouts, and therefore so high or continuous a temperature 
is not required. The success of the sterilising process largely depends upon 
getting the milk fresh and clean, and consequently containing few bacteria 
and no spores. It is impossible in a household to sterilise stale milk. 
Stale milk is certain to contain many spores, and the spores of some of the 
saprophytic bacteria such as those which attack casein require a tempera- 
ture of 100-105 C. or more to destroy them. If the milk can be procured 
fresh and clean and is intended to be consumed within a day or two, a tempera- 
ture of 70 or 75 C. is quite high enough to expose the milk to. This tempera- 
ture does not affect the taste or coagulate the lactalbumen. If milk has 
to be kept a longer time or is not very fresh, it is better to expose it to a 
temperature of ioo° C. for half an hour. Milk which is long heated at ico° C. 
or especially a higher temperature suffers certain changes, the chief of 
which is connected with the coagulation of the albumen and the partial 
destruction of the fat emulsion. In such milks some of the fat floats in the 
form of large globules of butter on the top of the milk when it is warmed. A 
brown colour is developed on account of the partial destruction of the lactose. 
Milk long heated suffers coagulation less perfectly than raw milk ; this is 
due to the precipitation of some of the calcium salts. There can be no 
doubt that the formation of the butter oil is a disadvantage; how far the less 
perfect coagulation of the curd is an advantage it is impossible to say. 

Various forms of apparatus have been devised for sterilisation in the 
household, the best known being on the Soxhlet type. This form can be 
used for heating to ioo° C. or to the lower temperature of 70 C. 
Hawksley has also devised a steriliser with a thermometer, which is con- 
venient and reliable. (See Appendix.) 

Condensed Milk. — Condensed milk has long been a favourite substitute 
for mothers milk among the lower classes, and its use is by no means con- 
fined to- the lower orders, though it has had but few defenders among 
medical men. The fact that some brands contain a large proportion of added 
cane sugar has condemned it in the eyes of most medical writers, and many- 
serious allegations have been made against it. It has been accused of pro- 
ducing eczema, diarrhoea, constipation, rickets, scurvy, and it has been 
alleged that while children who have been brought up on it are fat and 
plump, they readily succumb when attacked with acute disease. That it is 
a favourite food among the lower classes there can be no doubt ; it is con- 
venient, it does not readily turn sour, and it may often be substituted for 
fresh cow's milk, when the latter causes vomiting, with good effect. The 
reason of its being useful in gastric catarrh, not being vomited when cow's 
milk and water have been, is probably that the condensed milk, as generally 
mixed, contains less curd than the mixture of fresh cow's milk previously 
used ; it seems certain also that the casein of condensed milk is more slowly 
thrown down than the casein of fresh milk. 

[Moreover, it is sterile, and the best brands have been prepared from fresh 
rich milk. We believe that while it may often be substituted for fresh cow's 
milk with advantage, we should deprecate its use for many months together, 
if given as the sole food. 



Condensed Milk — Dried Milk Foods 51 

In using condensed milk accurate directions must be given as to the 
strength to be employed and also as to the manner of measuring it. A 
graduated measure should be employed and the milk poured into it. For an 
infant of three months old it may be diluted 1 in 8 by weight, or what is nearly 
equivalent to this, 1 in 10 by measure. It should rarely be used stronger 
than this, but it may be necessary to dilute to I in 15 or 20 for very young 
infants, or in special cases. 

Diluted to 1 in 8 by weight, we shall have the following composition 
(Leeds) : 

Condensed milk Diluted i in 8 by weight. 

Fat .... i2-io 1-51 

Lactose . . . 16-62 2-06 

Cane sugar . . 22-26 2*78 

Proteids . . . 16-07 2-01 

Ash .... 2-61 -32 

Total solids . . 69-66 8-68 

It is important only to use a good brand of condensed milk, inasmuch as 
the cheaper forms are deficient in fat. The ' Milkmaid ' brand contains 
nearly 12 per cent, of fat, while some other brands have less than 2 per cent. 

Some good brands of condensed milk may be obtained without added 
sugar. The following is an analysis of the ' Viking ' brand ; it will be seen 
that it corresponds with a good milk which has been concentrated by driving 
off two-thirds of the water. A measured ounce of this milk weighs 480 grs., 
that is one-tenth more than an ounce of water. It can be diluted for use 1 in 
4 or 6 by measure. 

Unsweetened Diluted 

condensed milk i in 6 by weight 

Fat .... 9-9 1-65 

Lactose . . . 13-3 2-2 

Proteids ... 8-9 1-5 

Ash i-q -16 



Solids . . . 34-0 



5V 



It will be seen by examining the second columns that each of these foods 
is deficient in fat, while the latter is deficient in carbo-hydrates, but this can 
be remedied by adding sugar. It is well to bear in mind that in all concen- 
trated or desiccated milks the calcic phosphates are thrown down in a more 
or less insoluble form, and in preparing the food in the ordinary way are 
only in part redissolved. 

Dried Milk Foods. — The difficulties attendant on the preparation and 
storage of sterilised milk for sale have brought into the market various 
preparations of desiccated milk. These will keep good in any climate, and 
occupy only a small bulk as compared with liquid preparations. They are 
unquestionably convenient, are sterile, and their proteids are more readily 
digestible than the proteids of much that passes as fresh milk. Messrs. 
Allen & Ilanbury prepare two forms of desiccated milk food. In these 
preparations the percentage of the proteids (both curd and albumen), also 
iat and sugar, is the same as in human milk. In Nt>. 2 food a small quantity 
of malt extract is added. The following analysis is from the v Lancet ' : 

v 2 



52 The Hygiene and Diet of Infants and Children 

A. & H.'s No. i food Diluted i in 8 by weight 

Fat . . . .13-15 1-64 

Lactose and dextrin . 65-48 8-19 

Proteids . . . 14-25 1-78 

Salts .... 4-75 -6 

In using this food accurate directions should be given for its preparation. 
The useful tablespoon should not be used as a measure, but a dry graduated 
measure glass. Six measured drachms (220 grs.) of Xo. 1 food weigh half 
an ounce, water is to be added to make up 4 oz. in all. 

The composition of Xo. 2 food is very similar. Xo. 1 is most suitable 
for the first three months of life, and-Xo. 2 for the next three months. Xo. 3 
food, which consists of a malted starch food and which requires mixing with 
fresh milk, is best suited for children over six months of age. 

Our own experience of these desiccated milk foods is decidedly favourable, 
and they are as a rule much more readily assimilated than diluted fresh milk, 
and in some instances answer better than peptonised milk. They are certainly 
worthy of a trial in those cases where an infant is vomiting or has curdy stools 
while taking diluted fresh milk, at least as a temporary resort. 

Amount of Food to be given. — The amount of food to be given to an 
infant must necessarily depend not only on its age, but also on its digestive 
powers and its development. It is evident that it is quite as important to 
carefully regulate the times of taking food and the amount to be taken, as it 
is to decide upon the nature of the food. It must of course be borne in 
mind that the amounts given below are for an infant of average weight and 
digestive powers. Xeither age nor weight should be taken blindly as a guide 
to the amount of food an infant should take. For the first two or three 
weeks (weight 6 to 8 lb.), give 1 to 2 ounces of food ever}' two hours and a 
half in the daytime; 8 bottles being given, and 12 to 15 ounces of food being 
taken in the twenty-four hours. 

During the second month (weight 8 to 11 lb.), 3 to 4 ounces of food ever}' 
two hours and a half; 8 bottles being given, and 20 to 30 ounces being taken 
in the twenty-four hours. 

During the third and fourth months (weight 11 to 14 lb.), 4 to 5 ounces 
of food every three hours ; 7 bottles being given, and 30 to 35 ounces being 
taken in the twenty-four hours. 

During the fifth and sixth months (weight 14 to 16 lb.), 6 to 7 ounces of 
food may be given every three hours ; 6 bottles being given, and 35 to 40 
ounces being taken in the twenty-four hours. 

Feeding- Bottles. — The simplest feeding bottles are the best. It is wise 
to avoid all those provided with india-rubber tubes, corks, and those that have 
indented letters on their surfaces. The rubber tubes soon crack and become 
rough inside, corks absorb some of the food and quickly become foul, while 
any indentations on the inner surface of the bottle make it difficult to scour 
clean with a brush. The best class of bottles are those with rather wide 
mouths (see fig. 9) or such as are supplied with Soxhlet's or Eschericlr s milk 
sterilisers, and are perfectly plain and fitted with large teats that can be turned 
inside out for the purpose of cleansing. The small teats supplied with the 
fancy bottles cannot be readily cleaned. The bottles after being used should 
be thoroughly cleaned with a brush kept for the purpose, and inverted so that 



Artificial Feeding — Diet from 6 to 12 Months 53 

they may drain and no dust may be allowed to get into them. It is important 
that the food should not be given too hot ; a tempera- 
ture of 98 F. is quite warm enough. 

Diet from 6 to 12 Months, — While some mothers 
are strong enough, and are sufficiently good nurses, to 
suckle their children to the end of the first year, there 
are many others who begin to flag about the 6th or 
7th month, and in such cases it is desirable to supple- 
ment the breast by means of some milk food. There 
is no lack of artificial or patent foods from which to 
choose. If the infant is entirely dependent upon arti- 
ficial food, it should take from i}to 2 pints of good 
cow's milk every twenty-four hours, between 6 months 
and 1 year. Whether this should be given undiluted 
must depend upon the digestive powers of the infant, 
which may be gauged by its pov/er of digesting casein 
as determined by an inspection of its stools and by 
its growth and weight. Some form of starchy food 
may be added with advantage, for now the digestive 
powers of the infant are sufficiently advanced to form 
dextrine and maltose out of starch, thus forming a 
valuable and easily assimilated carbo-hydrate. Care 
must be taken that all starchy matters are thoroughly 
boiled, so that the starch granules become gelatinised, 
as raw starch is less easily digested. 

Barley jelly, whole meal flour, maize, oatmeal, all 
answer very well if thoroughly cooked and made sufficiently thin to pass 
through the tube of ordinary feeding bottles. 

If the digestion of starch is not proceeding well or if curd is being passed 
in the stools, malt extract or ' Bynin ' may be added to the food after it has 
been boiled, and allowed to become just cool enough to taste ; it is then set 
aside for a few minutes before giving it.. Five meals in the twenty-four hours 
will, as a rule, be sufficient, some 6 to 8 oz. being taken at each meal. The 
first meal may be taken between 7 and 8 a.m. ; the second, between 10 and 
11 A.M. ; the third, 1 to 2 P.M. ; the fourth, from 4 to 5 p.m. ; and the fifth, 
the last thing at night. There is no harm in giving the infant a well-toasted 
crust to nibble, but thick foods should not be allowed, and beef tea or eggs 
are certainly unnecessary, and best avoided. 

During the 7th, 8th, and 9th months, 3$ oz. to 3 oz. will be an average 
weekly gain, and by the end of the 9th month 20 lb. weight maybe reached. 
During the last three months 2 oz. to \\ oz. per week ; and the weight is 
usually over 22 lb. by the end of the first year. 

It must not, however, be forgotten that infants may put on fat which 
naturally adds to their weight without their being necessarily strong and 
healthy. Care must be taken to weigh them at the same time ot day, so that 
there may be no mistake. 

At twelve months of age, if the child be strong and healthy, the bottle 
may be gradually left off, and food of a more solid character may be substi- 
tuted, but milk is still to be the staple food. 




54 The Hygiene and Diet of Infants and Cliildren 

Diet from Twelve XVXontbs to Eighteen Months of Ag-e. 

First meal, 7.30 A.M. Fine bread sops with milk, or oatmeal or hominy 

porridge made with milk. 
Second meal, 11 A.M. A drink of milk. 
Third meal, 1.30 P.M. Bread crumbs and gravy or a lightly boiled egg and 

bread and butter. Sago or rice pudding. 
Fourth meal, 5.30 p.m. Bread and milk. 
Fifth meal. Milk to drink. 

After eighteen months of age, when healthy children have cut their first 
set of double teeth, small quantities of fish, fowl, or meat may be allowed. Of 
fish, boiled whiting, sole, or cod, carefully freed from all the bones, is readily 
taken by most children. Boiled fowl is better than butcher's meat in early 
childhood. Of the latter, underdone mutton chops, torn into shreds and 
mixed with bread crumbs or well-mashed potatoes, form the best and most 
digestible kind of butcher's meat. Rice, sago, and tapioca puddings, stewed 
apples, and preserves of various fruits, may be allowed. 

Children unfortunately are often strangely fastidious in their tastes, and 
will frequently take a dislike to many forms of the most digestible foods. It 
is always well to introduce as much variety as possible into their diet. For 
older children hominy porridge with treacle for breakfast, to be followed by 
small quantities of bacon or egg, with cocoa or weak tea, are as a rule well 
digested and are beneficial, provided that the porridge or bread and milk 
forms the piece de resistance of the repast. Soups made in various ways 
from meat and vegetables form an exceedingly wholesome and digestible 
meal. Pastry, as a rule, is bad ; boiled rice with raisins and stewed fruit of 
various kinds are much to be preferred. 

When the child is old enough to sit up to table at dinner and take meat 
cut from a joint, the greatest care should be taken to see that the meat is 
carefully cut up into small pieces before being put into the mouth, and is 
thoroughly masticated before swallowing. So important is this, that if there is 
any doubt as to the cutting up by the nurse, it will be well to insist that all 
the meat should first be put through a mincing machine ; the gravy can 
be afterwards added to it. Masses of half-masticated meat will not be 
digested if bolted in the usual way, and will be passed almost unchanged in 
the faeces ; and if the food is thus bolted, it is less satisfying, and leads to 
more than is required by the system being consumed. A stand must always 
be made against the common practice of giving children biscuits or ginger- 
bread at almost all hours of the day. The stomach requires rest like every 
other organ in the body, and is certain to become deranged if sweet things 
are being taken at all times. 



55 



CHAPTER IV 

DISEASES OF THE DIGESTIVE SYSTEM 

Examination of the Mouth. — An inspection of the cavity of the mouth 
and fauces in infants and children is of great importance, and mistakes in 
diagnosis are exceedingly likely to be made if it is neglected. In newly born 
infants the mucous membrane of the mouth is comparatively dry, and con- 
tinues so for the first two or three months of life ; the secretion of saliva 
becomes gradually freer as the glands develop, and the infant begins to 
dribble, for it is some time before it learns to swallow its saliva and to keep 
its mouth shut. The lining of the infant's mouth is at first of a dull red 
colour, and flocculi of milk are often to be seen adhering to it, as the move- 
ments of the tongue and lips are imperfect, and there is but little secretion 
of fluid to cleanse the mucous membrane. All through infancy and early 
childhood the mucous membrane is exceedingly apt to become the seat of 
various lesions. The membrane is necessarily delicate, the epithelium is easily 
injured, and affords a favourable ground for the cultivation of cryptogamic 
growths and various micro-organisms ; hence the frequency with which we 
•find parasitic stomatitis and various superficial ulcerations and aphthous 
patches. 

Inspection of the mouth of the newly born may reveal various abnorma- 
lities, some of minor importance, such as the small millet-seed nodules 
situated in the middle of the roof of the mouth, a shortened frasnum linguae, 
or the presence of small clear swellings (ranula) beneath the tongue. Among 
the important abnormalities may be mentioned cleft palate, or an abnormally 
high arched roof. 

All through early life there is a tendency to hypertrophy of the lymphatic 
tissues in the naso-pharynx and fauces. It must be borne in mind that the 
passage through the naso-pharynx in infants is exceedingly narrow, and the 
presence of adenoid excrescences or enlarged pharyngeal tonsil, which may 
perhaps be congenital, may seriously interfere with the infant's respira- 
tion, and in some instances seems to excite k choking fits," or spasm ot the 
glottis. 

dentition. — The influence of dentition upon the health of the infant de- 
pends very much upon the child's constitution. A strong and \ igorous infant 
which has been brought up at the breast will cut its teeth one after another 
without trouble, and but for the appearance of the teeth through the gums 
the friends will not be aware that dentition is in progress. On the other 
hand, if the infant is rickety, weakly, or the victim ot" hereditary tendencies, 
the period of dentition will be a period ot danger. And the irritation caused 



56 Diseases of the Digestive System 

by the pressure of the tooth expanding its socket and cutting through the 
gum is very liable to give rise to various forms of disease, the process of 
dentition acting rather as the exciting than the predisposing cause. The 
first dentition begins during the middle of the first year, and ends usually by 
the appearance of the posterior molars in the middle of the third year. In 
some, without any known cause, the first teeth make their appearance before 
this time ; indeed, it is not infrequent for infants to be born with a tooth 
already cut ; such teeth, however, are imperfectly developed, and consist 
merely of a thin shell of enamel. Some by no means strong children cut 
their teeth early. In rickets dentition is delayed ; in those cases in which 
rickets makes its appearance prior to the sixth month, dentition may not 
commence during the first year, the infant being toothless at a year old. In 
other cases the infant only becomes rickety towards the end of the first 
year, when the incisors are perhaps through the gum, and then there follows 
a long delay. 

By the fifth or sixth month saliva is formed in large quantities, so that it 
is frequently dribbling from the mouth, and the infant is constantly putting 
its finger into its mouth, as if there were some sort of irritation going on 
there. Moreover, while up to this period it has taken its food well and slept 
the whole night without disturbing its mother, it now becomes restless, wakes 
crying, suffers from dyspepsia and flatulence, and is at times feverish. The 
gums may become tender, the whole mucous membrane congested, aphthse 
appear on the tongue, inside the lips, or on the hard palate, and the infant is 
feverish and cross to a degree. Perhaps now the edge of a tooth, usually 
one of the lower middle incisors, will be felt through the gum. Some days 
or even weeks will perhaps elapse before the edge of the tooth is actually 
cut. It is a singular but by no means unusual circumstance for a tooth to 
advance so as almost to stretch the mucous membrane of the mouth, and 
then become stationary for some time. 

Now while it is the almost daily experience of the practitioner that 
the process of cutting the first teeth gives rise to various troubles, he 
knows also that mothers and nurses are ever ready to attribute every 
childish illness to the teeth. Many infantile ailments are mysterious in their 
origin, especially attacks of feverishness, and in children under two years old 
there is always a tooth nearly cut, or has just been cut, or is about to be 
cut, to supply the explanation. It is this popular tendency to attribute 
every childish ailment to the teeth, which explains the ready sale of 
' teething powders.' The danger is that important errors in diet, a patch 
of pneumonia, or a meningitis may be overlooked if the teeth are allowed to 
explain everything. While it is unwise to shut our eyes to the disturbance 
and discomfort produced by a stretched and swollen gum, care is needed to 
avo d using the explanation of ' tooth cutting' to cover ignorance or merely 
to satisfy the clamour of an anxious mother for a definite opinion as regards 
her child's illness. It is a good rule always to seek for an explanation 
elsewhere than in the teeth, if there is no local lesion in the gum, such as 
swelling, tenderness, or some evidence of inflammation. 

Feverishness. — When the gum is swollen and tender prior to the cutting 
of a tooth, the infant is apt to be irritable, having fits of crying without any 
apparent cause, which nothing will pacify ; at first gently rubbing the gum 






Dentition 5 7 

will give ease, but at a later stage this only aggravates the trouble from the 
acutely painful state of the gum. The fever is intermittent, the child being 
hot and feverish for the most part at night and unable to sleep, while towards 
morning it cools down and dozes for a few hours ; the temperature may 
reach 102 or 103 , rarely more. Such attacks may often pass away without 
the tooth being cut, or may continue for some time after the edge of the 
tooth has appeared, and before the rest of the tooth has made its way 
through. 

Stomatitis. — The mucous membrane of the mouth, more especially that 
part of the gum where the tooth is about to appear, the tongue, hard palate, 
and inside of the cheeks, may be the seat of small superficial ulcers or small 
spots denuded of epithelium, their surface being of a grey or yellowish 
colour, and their edges surrounded by a zone of erythematous redness. 
These spots are evidently sore, and may be the cause of the infant refusing 
the breast, and crying whenever liquids containing salines, such as beef tea, 
are taken. 

Enlarged Glands. — Occasionally it happens in children predisposed to 
glandular enlargement that the irritation caused by these aphthous patches 
gives rise to a swelling of the glands, either the submaxillary when the lower 
jaw is affected, or the parotid or upper cervical lymphatic glands, which receive 
the lymph from the upper jaw. These swellings may quickly subside, or 
end in either acute or chronic suppuration. In the latter case successive 
teeth being cut keep up the source of irritation. 

Diarrhoea. — During the hot months of late summer and autumn, the 
irritation of teething may be the exciting cause of intestinal catarrh and 
diarrhoea. In infants a transference of a lesion from one part of the body, 
more especially from one mucous membrane to another, is exceedingly 
common ; this diarrhoea is especially common in artificially fed infants. No 
diarrhoea should be attributed to tooth cutting, unless there is some local 
lesion in the gums or mouth. 

Bronchitis. — During dentition, especially when the incisors are being cut, 
infants seem very prone to catarrh of the bronchial tubes, which maybe 
complicated by catarrhal pneumonia. 

Eczema and Lichen. — It constantly happens that infants who suffer, or 
are liable to suffer, from eczema are much worse while a tooth is pressing 
through the gum. The eczema very frequently gets well in the intervals, 
the face and body being free, until a tooth comes near the surface, and there 
is a return of the eczema, the face and forehead flush up and papules appear 
which begin to ooze and crust. Lichen in the form of strophulus or urticaria 
is also common. 

Convulsio?is. — It may be taken for granted that no healthy infants suffer 
from convulsions ; those who do are either rickety or the children of neurotic 
parents, and inherit a tendency to nerve disturbance. Spasmodic affections 
of various groups of muscles occasionally take place. 

Treatment. — Much controversy has arisen from time to time with regard 
to the use of the gum lancet, and the propriety of employing it in assisting 
dentition, many practitioners being in the frequent habit of using it, while 
others have not employed it for years. If the mucous membrane over the 
tooth is red, swollen, and tender, and the edge of the tooth can be felt, much 



58 Diseases of the Digestive System 

pain and discomfort will be spared the infant by its use, presuming, of 
course, it is not a 'bleeder,'" nor comes of a family in which there is a history 
-of haemophilia. The relief afforded is due in all probability to the local 
loss of blood, as well as to the relief of tension in the gum. That it has been 
done often unnecessarily, and that many troubles are attributed to dentition 
that have no connection with it, is no argument against the use of the lancet 
in proper cases. The evidence is too strong to be lightly explained away, 
that fits of crying, feverishness, or even convulsions may be quickly relieved 
by freely lancing a swollen and tender gum. It, perhaps, need not be said 
that it is useless to lance the gum unless there is evidence that the cutting 
edge of the tooth is near the surface, or disappointment will certainly follow. 
In one case coming under our notice, in which an upper incisor was lanced in 
a rickety child, the tooth was not cut till exactly a year after the operation. 
The feverishness and tenderness in the mouth and sleeplessness may be 
.generally relieved by mercurial purges, bromides, or simple salines (F. i 
and 2). As much as five grains of bromide may be given if the infant is 
very restless, or two or three grains of chloral hydrate, or a mixture 
containing two and a half grains of each in a teaspoonful of syrup. Painting 
a tender and swollen gum with a saturated solution of bromide of sodium in 
glycerine and water will often relieve pain. If the gums remain spongy, or 
there is aphthous stomatitis, borax with tinct. myrrh may be used (F. 3). 

The temporary teeth differ in size and hardness in different children ; 
in weakly rickety children they are not only late in appearing, but 
when they do appear are dwarfed and consist of mere shells, quickly 
becoming black and carious, or loose and falling out of their sockets. In 
other children the enamel appears deficient, and caries occurs early. Great 
•care should always be exercised in the preservation of the first set of teeth. 
A soft tooth brush should be used every night, and the mouth thoroughly 
-cleansed with warm water, in order to dislodge the fragments of food which 
have collected between the teeth. If the teeth show signs of caries, it is a 
good plan to use the tooth brush after every meal, mixing a few drops of an 
alkaline mixture with the water (sp. ammon. aromat. 5J, sp. vini rect. §iij). 
Whenever it is possible, carious temporary molars should be properly filled. 

The second dentition is not accompanied by the same troubles as the 
first, or at any rate to the same degree. The first molars and incisors usually 
make their appearance unobserved, and rarely occasion any inconvenience. 
The second molars may give more trouble. It sometimes happens that the 
gums get into an unhealthy state, being spongy and bleeding readily, while 
the teeth become loose and give pain during mastication. It is during this 
period that ulcerative stomatitis may be present. Gumboils may be another 
source of trouble. If it is of importance to attend to the cleansing of the 
mouth during early childhood, it is of still greater importance to do so when 
the permanent teeth are appearing, and no effort should be spared to prevent 
their premature decay. 

The structure of the permanent teeth is no doubt influenced by the 
state of the health during infancy. We have already referred to the fact 
(p. 13), that illness taking place during the first year of life may affect the 
permanent set of incisors, canines and first molars, while the bicuspids and 
last two molars escape. Mr. Hutchinson long ago pointed out that 



Stomatitis 5 9 

-congenital syphilis often gives rise to a peculiar formation of the incisors of 
the permanent set. The ' test teeth ' for syphilis are the ripper central 
incisors ; the effect of this disease occurring during infancy is to arrest their 
development, causing dwarfing and also a central notch at the cutting edge, 
or perhaps a ' screw-driver ' form of tooth ; the other incisors may share in 
this want of development, but only in a secondary degree. Mr. Hutchinson 
has also pointed out that stomatitis occurring during infancy gives rise to a 
pitting or erosion of the enamel. The 'test tooth' for infantile stomatitis 
being the first molar, the incisors also may be affected, and they may be 
grooved by a ' transverse furrow crossing all the teeth at the same level.' 
In some cases the pitting of the upper surface of the molar produces well- 
marked rugosities (erosion en ?namelo7i). Other deficiencies of the enamel 
of more or less extent have been described by French authors. Mr. 
Hutchinson believes that the stomatitis giving rise to this condition is often 
mercurial in its origin, mercury having been given in the form of ' teething 
powders' or in other ways. Mr. Moon used to speak of a ' mercurio- 
syphilitic' tooth in which there was a want of enamel over a semi-lunar 
space near the cutting edge, and in consequence a breaking down of the 
enamel over this area. M. Magitot attributes erosion of the teeth to the 
effects of infantile convulsions, but it is probable the convulsions are 
coincident only. 

It is by no means always easy to explain why some children have good 
teeth with perfect enamel, while in others the enamel is deficient and the 
teeth quickly become carious. There cannot be any doubt, however, that a 
strong and vigorous infancy and early childhood with a good digestion and 
careful feeding must favourably influence the development of the teeth ; 
while infants who suffer from dyspepsia and are badly fed will suffer later 
on from bad teeth. No doubt apparent exceptions may occur. 

Diseases of the XVSouth 
Catarrhal Stomatitis. — Catarrhal inflammation of the mouth may be 
primary, but it is more often secondary, accompanying dentition, dvspepsia, 
pneumonia, and other diseases. Stomatitis is especially apt to make its ap- 
pearance during the first year of life, though it is common during the'whole 
of childhood. Infants who are thus suffering, having begun to take the breast, 
suddenly let it go and cry, and are apt to stuff their fingers in their mouths ; 
they are feverish and irritable, the saliva is increased in quantity, and the 
mouth feels hot if the finger be inserted ; the salivary glands, especially the 
sublingual, are swollen and tender. On examination of the oral cavity, 
patches of intense redness are to be seen on the mucous membrane inside 
the cheek, on the gums, or hard palate, the tongue is generally bright red 
and clean, or the surface is covered with a thick creamy fur, the edges and tip 
being clean and red. This form of stomatitis is often called stomatitis 
erythematosa. Very frequently at the seat of these erythematous patches, 
an exudation of yellowish or greyish secretion takes place, or there is a 
breach of surface where the epithelium is abraded, and small shallow- 
ulcers arc formed. These yellowish patches or ulcers are surrounded by 
a zone of redness. Such patches are usually termed Aphtha*, and when 
present the term 'aphthous stomatitis ' is often applied. Older children are 



6o Diseases of the Digestive System 

subject to these attacks, and it is often seen to affect a whole household at 
the same time, the adults by no means always escaping. It is uncertain if 
it is contagious, but it is certainly epidemic ; it is sometimes associated 
with tonsillitis. There may be feverishness, the temperature rising to 103°, 
accompanied by the appearance of vesicles on the mucous membrane of the 
lips, tongue, and soft palate ; the vesicles soon disappear, being followed by 
patches of yellow exudation, or a shallow ulcer may remain. The spots 
remain sore for several days. Similar attacks have been described as 
occurring both in infants and children from drinking the unboiled milk of 
cows suffering from ' foot and mouth ' disease ; and in any case where these 
affections occur in a widespread epidemic it is well to make careful inquiry 
into this as a possible cause. 

It is probable there are several distinct diseases resulting from specific 
micro-organisms included under the term ' aphthous stomatitis.' 

Fraenkel has found pus cocci, such as Staph, pyog. citrens and a/bus, as 
well as ' gas-forming bacilli,' in stomatitis. 

During attacks of tonsillitis, scarlet fever, measles &c. aphthae often make 
their appearance on the tongue and inside the lips, while the corners of the 
mouth become excoriated. 

In infants, aphthous patches, two in number, situated on the hard palate, 
one on each side of the median raphe, near the junction of the hard and soft 
palate, are often seen ; these are round superficial ulcers £-| in. in diameter, 
their base being of a yellowish colour and surrounded by erythema. They 
have been described as Bednar's aphthae, or plaques pterygoidiennes by 
Parrot. They are produced by the pressure of the back of the tongue against 
the hard palate in sucking. They have nothing to do with syphilis. 

The treatment must depend upon the cause, whether the stomatitis 
depends upon dentition, gastro-intestmal catarrh, or other pathological con- 
dition. In most cases a mild purge will be useful to expel any indigestible 
food present in the alimentary canal, to be followed by one or two grain doses 
of chlorate of potash in a little glycerine and water (F. 4). 

Locally the spots may be touched with a solution of permanganate of 
potash (5 grs. to the oz.) or boracic acid (15 grs. to the oz.). If the spots are 
slow in healing, they may be touched with lapis divinus. This latter consists 
of equal parts of sulphate of copper, alum, and saltpetre fused together. The 
diet should consist of milk and barley water made more dilute than usual, 
and for older children milk and sops. Beef tea and saline fluids are generally 
objected to on account of causing smarting in the mouth. 

Parasitic Stomatitis. Thrush. — This form of stomatitis differs essen- 
tially from the forms already described, as it is due to the presence and growth 
in the epithelium of the mouth of a species of cryptogam (0 2 dium albicans). 
It is especially common in newly born infants and in those of a few months 
old, who are suffering from some form of wasting disease, and in whom the 
mucous membrane of the mouth is in an unhealthy condition. But it is also 
found in infants during the last half of the first year, less commonly during 
the second and later years. It appears as small white distinctly raised 
points or scattered patches on the soft palate, mucous membrane of the cheek, 
lips, and tongue. While its chief seat is the mouth, it has been found in the 
larynx, oesophagus, stomach, caecum, and in one or two instances in the lungs. 



ThrusJi 



61 



If touched with a small paint brush, the patch is found to adhere firmly to 
the mucous membrane and cannot be detached as can milk flocculi, for 
which it may readily be mistaken ; if forcibly detached there is left a red 
surface denuded of epithelium. The mucous membrane of the mouth is 
often red and unhealthy around the patches, in other cases it is quite normal. 
In mild cases these white patches are small and few in number ; in severe 
cases they become confluent and large, and the surface of the tongue and 
cheeks is covered with them. Infants so affected are mostly weak and ill, 
and often suffer from diarrhoea or gastric catarrh with wasting. It occurs 
in older children in the last days of tuberculosis, tubercular meningitis, 
typhoid, and pneumonia. 

If a piece of the white patch be detached and examined microscopically, 
it will be found to consist of epithelial cells, bacteria, yeast fungi, and the 
thread-like filaments of various mould fungi. The identity of the fungus 
which gives rise to the disease is a matter of uncertainty, the difficulty of 
identifying it being largely due to the presence of various organisms in the 
white patches. It has been iden- 
tified as the Oidium lactis, the 
mould fungus which is present in 
sour milk ; the cultivations of 
Grawitz led him to believe it to 
be identical with the yeast fungus 
or wine ferment {Saccharomyces 
77iy coder 771a). Rees, who further 
investigated it, believes it to be a 
yeast fungus, though not identical 
with the above ; he gave it the 
name of Saccharomyces albicans. 
The micro-organism of thrush is 
most probably, as Fraenkel states, 
a link between the yeast fungi 
(Saccharo77iycetes) and the mould 
or thread fungi {Hypo77iycetes). It can be cultivated in syrup, gelatine, 
or potatoes and bread paste ; under certain conditions of nutrition it 
appears to resemble the yeast fungi, as on the surface of the gelatine ; 
while at the bottom of the test-tube cultures it appears more like the thread- 
like forms of the mould fungi. It is aerobic, and does not liquefy gelatine. 

Plaut believes it to be identical with a fungus growing on sweet fruits 
and rotten wood (Monilia Candida). 

The fungus usually appears in the form of filaments made up of cells 
jointed together 3-4 /x broad and 50--60 /x long ; these branch in various 
directions ; oval cells bud out from the joint between the elongated cells ; 
spores are present in these roundish cells. (See fig. 10.^ 

Treat7iient. — It is of muoh importance that great care should be taken to 
cleanse the mouth after the infant has taken the bottle, especially in a weakly 
infant of low vitality, weak alkaline solutions, just tinged with Condy*s Fluid, 
being useful for this purpose. This can be done with a large paint brush or 
soft wet rag, and on the first symptoms of thrush the borax lotion 1". 
similar solution should be used. As a stronger application to the parasitic 




— Fungus of thrush ( x 300). 
{AJter Crookshank.) 



62 Diseases of the Digestive System 

patches a solution of sulphate of copper (2 grs. to the oz.) or carbolic acid 
(2 grs. to the oz.) is very effectual when applied with a paint brush. The 
success of the treatment depends not only on the destruction of the fungus, 
but also on an improvement in the child's general health. 

Ulcerative Stomatitis. — This form mostly occurs during dentition, 
and is perhaps most common during the period of the second dentition, or 
from the age of five to ten years. The children who suffer from it in the 
severe form are unhealthy, and are either recovering from some infectious. 
disease, or have been badly fed, or have been exposed to unhealthy sur- 
roundings ; it is also common in tuberculous children. A very similar con- 
dition is produced by scurvy-rickets, and by chronic mercury or phosphorus 
poisoning. The first symptoms consist in increased salivation, the gums 
become pale, swollen, and spongy, and the breath foul ; the salivary glands 
are swollen and painful, and there is often much swelling of one or other 
lip. The spongy gums bleed, and the blood together with the matters 
taken as food decompose, giving rise to a very foul condition of the breath. 
The first part of the gums to be affected is usually that near the incisors or 
eye teeth of the lower jaw ; the front part of the gums suffers more than the 
back. The gums sometimes swell so as to partly cover up the teeth, irregular 
ulcers form on the swollen gums, which, as they increase, expose the roots 
of the teeth ; the latter become loose and perhaps fall out. The ulceration is 
at first confined to the gums, but may involve the sulcus between the gum 
and cheek, and also the mucous membrane lining the cheek or the inside of 
the lower lip. In mild cases the symptoms are much less severe than this. 

Necrosis of the jaw is apt to follow in some of the more severe cases of 
ulcerative stomatitis ; instead of the process ceasing, as it usually does, the 
mischief spreads and a chronic osteomyelitis of the jaw is set up, much 
intensely foetid discharge comes away, the child's health suffers, the cheeks 
become puffy and flabby, the ulceration of the gums spreads, and after a 
while it is found that a large piece of jaw, carrying perhaps two or three 
teeth, is loose ; this is taken away, and in some instances the process stops ; 
often, however, any new bone that may have formed becomes infiltrated with 
the foul discharges, and the mischief spreads along the jaw, piece after piece 
is taken away, until at last the entire jaw may have to be removed. We have 
removed the whole bone from condyle to condyle for this condition. Many 
surgeons believe that the disease begins as a periostitis and not as an 
ulceration of the gums, and that alveolar abscess is the starting point ; this 
is so sometimes, though we think certainly not always. 1 

The child's health materially suffers from the discharge and foul state of 
the mouth. In one instance, after removal of the jaw, the child was sent 
home convalescent, but died suddenly, apparently from falling back of the 
tongue. Restoration of the jaw is very imperfect in these cases, for the new 
bone necroses as fast as it forms. The process closely resembles phosphorus 
necrosis, but it is not due to that poison. 

Treatment. — After every meal the mouth should be well rinsed with 
warm water or Condy's Fluid, and the gums and teeth cleaned with a bit of 
absorbent wool or soft rag, not sponge, so that the same bit may never be 

1 Dr. Angel Money has reported a case coming on after typhoid and affecting the 
upper jaw. The lower jaw is the one most commonly attacked. 



Alveolar Abscess 63 

used again ; the gums should then be mopped over with the glycerine of 
borax 2 parts to tincture of myrrh 1 part. Of internal remedies, by far 
the most efficient is chlorate of potash, given in five or six grain doses three 
times a day. The diet should consist of fluids and sops, beef tea and other 
nourishing liquids being given freely, especially in those cases where the 
disease occurs in the poorly nourished and underfed. This treatment will 
usually suffice to arrest the disease ; but once the bone becomes seriously 
involved, in some cases nothing seems to have any effect. Strong nitric 
acid, carbolic acid &c. seem to have little power, and the purulent infiltra- 
tion only ceases when the whole bone has been destroyed. These plans 
should, however, be carefully tried, chloroform being of course given, and 
subsequently there should be very frequent cleansing of the mouth with 
equal parts of rectified spirit and water. As soon as the disease has ceased 
to spread, any loss of bone or teeth should be supplied by a plate with arti- 
ficial teeth, to prevent falling in of the lips and the prematurely senile 
appearance thus produced. Even where the alveolus alone is destroyed, 
since no new formation of bone occurs the permanent teeth are often 
loosened and fall out. 

Alveolar Abscess is, as might be expected, a very common result of the 
neglect or mismanagement of carious teeth. After an attack of toothache 
the pain may completely subside, and swelling of the face over either the upper 
or lower jaw rapidly come on. This, of course, means that the inflammatory 
process — hitherto limited to the alveolus, and hence giving rise to great- 
pain, because there is great tension on a large nerve — has extended to 
the soft parts covering the bone by escape of the pus from the alveolus. 
The pain is greatly lessened, or ceases altogether. The condition is thought 
of little importance, and no steps are taken to obtain advice, as there is 
no longer pain, and a swelled face is looked upon as the natural and proper 
ending of a toothache. No doubt most of these cases get perfectly well 
at least for a time, for the abscess bursts either by the side of the tooth 
or more often through the alveolus and gum, and discharges itself into 
the mouth. Finally, the abscess closes up, and all remains quiet till some 
failure of health or some irritation rouses the carious tooth to another 
outbreak. In not a few cases, however, neglect to remove the source of 
irritation — i.e. the carious tooth— gives rise to one or other of the following 
troubles. Often a sinus remains inside the mouth leading through the 
alveolus to the fang of the dead tooth, and a constant discharge of a small 
quantity of foul pus takes place within the mouth. Such a condition cannot 
but be prejudicial to a child's health. The breath is foul, and the foul fluid 
is swallowed, poisoning alike the lungs and stomach, and often a child is 
kept ailing for months, for want of extraction of a carious tooth. In other 
cases, the abscess tracks to the surface and is allowed to burst there, giving 
rise often to a lifelong disfigurement, in the shape of a depressed scar over 
upper or lower jaw. Or, again, a chain of enlarged Lymphatic glands or a 
glandular abscess owe their origin to neglect o( a carious tooth or alveolar 
abscess. Necrosis of the jaw often results from similar neglect. Occasionally, 
too, we see cases of antral abscess in children as a result o\ extension of 
mischief from a tooth, though it is perhaps less common in children than we 
might expect. There is a most unreasonable objection both on the part of 



64 Diseases of the Digestive System 

parents and of some dentists to extraction of teeth, even if they are ex- 
tensively carious, and even if they are only temporary teeth. It is difficult 
to believe that the retention of a dead or carious temporary tooth can do any- 
thing but harm to the jaw and the underlying permanent teeth. It is perhaps 
still more difficult to understand the principle on which objection is made 
to the removal of a tooth while there is an abscess present, yet it is constantly 
done, and delay is urged till the abscess is well. In all cases a carious 
temporary tooth should be removed at the least sign of inflammation about 
it or if it causes foul breath. In all cases a tooth that has given rise to an 
alveolar abscess should be removed, and if its extraction does not empty 
the abscess a free opening should be made inside the mouth, and the abscess 
cavity and whole mouth frequently washed out with some antiseptic lotion 
till all is well again. On no account should an abscess be allowed to track 
towards the surface of the face, nor should any tooth be allowed to remain in 
the jaw with a sinus leading down to its fang. If antral abscess is met with 
or necrosis of the jaw, they must be dealt with by the ordinary methods, 
bearing in mind the softness and thinness of children's bones. We have 
now (1895) under our care a child with extensive tubercular disease of both 
antra, which probably arose from the irritation of carious teeth. 

Cancrum Oris. — Cancrum oris occurs almost invariably in squalid, half- 
starved children after one of the exanthemata ; sometimes, however, it seems 
to have no such predisposing cause. The disease begins as an inflamed 
spot on the inner surface of the cheek or upon the gum, the mischief rapidly 
spreads, both in depth and area, and the whole thickness of the cheek and 
gum becomes involved. On the outer surface the cheek is swollen, shining, 
stiff, and pale, or sometimes dark red, its vessels are thrombosed, and soon 
a black spot appears in the centre of the pale waxy area ; the cheek is per- 
forated, the black spot becomes a definite slough which partially separates. 
Then the edges of the gap become black and the sloughing spreads, pre- 
ceded by a zone in which the skin is pale and cedematous. In severe cases 
the whole side of the face is rapidly destroyed, the gums slough away, the jaw 
necroses,, and the teeth drop out. There is intense fcetor of the discharge 
and breath, which poisons the child, frequently causing pneumonia and 
death before the process is complete. Dr. Wilks considers that when 
the sloughing attacks the gum first it may be only an aggravated form of 
the ulceration met with in a late condition of scarlet fever ; this is seen 
usually in the lower jaw, while in true cancrum oris the upper jaw is 
attacked. 1 

Sansom has described an organism which he found in the blood and 
diseased tissues. When taken from the blood and inoculated into guinea 
pigs and mice, it was found again in their blood. 2 In a fair number of 
instances the process is arrested and the sloughing ceases, the parts clean 
up and heal rapidly, leaving, of course, a more or less severe deformity. In 
fatal cases death is due to exhaustion or septic pneumonia. The amount 
of pain and distress suffered is variable, sometimes but little of either exists. 

Treat?nent. — The treatment of cancrum oris consists in the free local 
application of the actual cautery, or, better, of pure nitric acid. The child 

1 An excellent description and figure are given in Mr. Cooper Forster's book on the 
Surgical Diseases of Children. - Med.-Chir. Trans. 1878. 



Carter u))i Oris — Acute Tonsillitis 



^s 



should be put under chloroform and the parts carefully dried with lint ; 
sticks dipped in strong nitric acid should then be rubbed well into the 
edges of the sloughing parts and over the surface of the gums, after cutting 
away any loose sloughs and removing sequestra. Care must, of course, be 
taken not to allow the acid to run over the sound skin. Several applica- 
tions of the acid should be made, the parts being dried after each. After- 
wards, a little iodoform should be powdered on and the surface smeared 
well with carbolic oil. E. C. Kingsford has had good results from the appli- 
cation of perchloride of mercury, but it has not proved universally successful. 1 
No less important than the local treatment is the free administration of 
stimulants and abundant nourishment. 
As much wine or brandy as the child 
will take (about 3-4 ounces of brandy 
in twenty-four hours for a child of five 
years), carbonate of ammonia and bark, 
eggs beaten up with milk, strong soup 
and meat extracts should be given. In 
these cases, as in phlegmonous erysi- 
pelas, patients seem to be able to take 
almost an unlimited amount and to 
thrive upon it. Opium should be given, 
but with caution, as it is not always 
well borne. If the child recovers, the 
deformity is often remediable to a con- 
siderable extent by a plastic operation. 
Perhaps the most troublesome after 
condition is closure of the mouth by 
adhesions ; an attempt to prevent this 
should be made during healing by the 
use of screw gags or mouth-openers, 
and later, by division of the scar tissue ; 
in some cases even section of the jaw , 
and the establishment of a false joint 
may be required. It must be confessed, 
this cicatricial contraction is far from sati 
good result is obtained. 

Some cases of cervical cellulitis (so-called angina Ludovioh closely re- 
semble cancrum oris in their results. ( Vzd DISEASES OF Lymph GLANDS.) 

Acute Tonsillitis.— It is hardly possible to exaggerate the importance 
of a thorough examination of the throat of 1 feverish child, especially when 
the cause of its illness is not obvious. A child, more particularly a young one. 
does not, like an adult, volunteer the information that its throat is sore and 
painful during the act of swallowing, and w even deny that it is sore when 
it is actually suffering from severe lonsillii Without a careful examina- 

tion it is quite possible to overlook not 01 
diphtheria, especially if there is some eh. 
the observer off his guard ; or he may com 
submaxillary 'mumps,' or croupous pneumi 

1 / ancet Sent. 1 




F-i.u.. 11. — Deformity resulting after recovery 
from cancrum oris; subsequently remedied 
by a plastic operation. Dr. Wilkinson's case. 



however, that the treatment of 
sfactory, and often no permanent 



tonsillitis but scarlet fever or 
omplication present to throw 
> the conclusion that a case o\ 

with physical si^n> delayed, 



66 Diseases of the Digestive System 

is a case of scarlet fever. Anyone who has had any experience of a fever 
hospital will be able to call to mind many cases where errors have been 
made through neglecting to examine the tonsils or from want of knowledge 
of their appearance in health and disease. 

Children are very liable to tonsillitis in its broadest sense, and this is in 
harmony with the fact that the lymphatic system during childhood is ex- 
tremely active and especially prone to inflammation. The use which the 
tonsils fulfil is uncertain, but, whatever their exact function, it is certain 
that they belong to the lymphatic system, and they have been justly com- 
pared to Peyer's patches, inasmuch as they resemble them in structure, con- 
sisting of congeries of lymph follicles or so-called ' solitary glands.' They 
have a large blood supply and their lymph sinuses freely communicate 
with the lymphatics of the mouth and pharynx, and also with the deep 




Fig. 12. — Vertical section of human tonsil (x 20), Landois and Stirling. 
1, crypt ; 2, epithelium infiltrated with leucocytes below and on the left, 
but iree on the right ; 3, adenoid tissue with sections/;./;./^ of masses of 
it ; 4, fibrous sheath ; 5, section of mucous gland duct ; 6, blood-vessel. 

cervical glands situated behind the angle ot the jaw. Their surfaces are 
covered with deep clefts or crypts which serve to increase the surface of the 
mucous membrane covering them ; these are apt to become filled with thick 
yellowish secretion, and are then seen as yellow points scattered over the 
surface. One of the functions of the tonsils is probably the formation of 
leucocytes, or white-blood corpuscles, which are shed into the salivary secre- 
tion, and the cheesy secretion formed during inflammation consists princi- 
pally of these bodies. Tonsillitis occurs under the influence of many different 
conditions during childhood, and possibly the proneness of the tonsils to 
inflame is, in part at any rate, the result of their position at the entrance of 
the fauces, where the various forms of aerial poisons, bacilli or other germs, 
would, when inhaled, be especially prone to lodge. Many of the zymotic 
diseases are accompanied, or, what is a very significant fact, are preceded, 



A cu te To nsil litis 



67 



by tonsillitis. Thus the tonsils are the seat of inflammation in scarlet fever 
.and diphtheria. Typhoid fever sometimes commences with a sore throat, 
measles and rotheln are mostly attended with some congestion or catarrhal 
inflammation about the fauces. The tonsils are apt to become inflamed as 
the result of cold, as from a wetting or exposure to a draught or keen east 
•wind, and possibly also from some gastric disturbance. There can be little 
doubt also that tonsillitis is at times due to inhaling sewer gas or unwhole- 
some smells. It also appears sometimes to precede or accompany an attack 
of acute rheumatism, or peri-endocarditis. 

The record of tonsillar complication is not complete without reference 
to the epidemics of sore throats which are apt to occur in schools, hospitals, 
and other public institutions, or wherever many children are brought 




Fig. 13.— Acute Tonsillitis. «, child aged three years ; b, child aged 4 years. _ These 
two cases belonged to an epidemic of sore throats ; scarlet fever was not certainly ex- 
cluded, but in no case was there a rash. 



together. Some of these epidemics have appeared to be modified scarlet 
fever or diphtheria, as proved by their belonging to a scarlatinal or diphthe- 
ritic epidemic which was coexistent in the neighbourhood or preceded or 
followed the epidemic of sore throats. But in other cases it has been clearly 
•shown that there is an epidemic or infectious form of sore throat which 
closely resembles both scarlet fever and diphtheria, but which, while similar 
in many respects, is actually distinct, as shown by its not protecting from 
•either of the above diseases. 1 Some cases of epidemic sore throat have 
apparently been traced to the consumption of the milk of cows suffering from 
'foot and mouth ' disease. Whenever sore throats occur in a household or 
school, the possibility that they are the result of the scarlatinal or diph- 
theritic poison should always be kept in view, while at the same tunc the milk 

' Vide Tonsillitis in Adolescents, by C. Haig-Brown, MP. 



68 Diseases of the Digestive System 

supply and the sanitary condition of the establishment should be carefully 
investigated. 

To whatever cause the tonsillitis is due, whether sporadic or epidemic, 
the symptoms are mostly the same. The attack usually begins suddenly, 
though it is often preceded for a few hours by a feeling of soreness in swallow- 
ing. Unlike scarlet fever, it is usually unattended by vomiting ; the evening 
temperature runs up to 103 or more, the tonsils are swollen and red, there 
is much secretion of mucus, and in a few hours yellow points make their 
appearance upon the tonsils, the result of secretion retained in the crypts. 
(See fig. 12.) The tongue is furred, but does not become of a ' strawberry ' 
appearance as in scarlet fever. In some cases, instead of the yellow points 
seen on the tonsils there is a yellowish exudation formed by the coalescence 
of the yellow spots on the inner surfaces of the tonsils ; this does not adhere, 
as a rule, with any degree of firmness, and may be removed with a brush. The 
inflammatory lesion remains for the most part tonsillar, and shows but little 
tendency to spread and involve the nasal mucous membrane or the middle 
ear, and, while the glands of the angle of the jaw may become enlarged, 
they are not hard or surrounded by cellulitis. There is no true ulceration of 
the tonsils or sloughing of the palate. The temperature remains remittent 
for a few days, gradually returning to normal. 

Such is the clinical history of an attack of acute catarrhal tonsillitis, but 
it must be remembered that many such attacks are exceedingly mild, and 
are accompanied by but little pyrexia, and may perhaps come and go with- 
out much complaint being made about them. Acute tonsillitis from any 
cause is apt to leave the tonsils enlarged, and the mucous membrane 
covering them in a condition of chronic catarrh. Repeated attacks in 
children liable to glandular swellings, accompanied as they are by catarrh 
of the naso-pharynx in many cases, give rise to various troubles which will 
be described later on. 

Diagnosis. — The most important question to consider, when called to 
see a case of tonsillitis, is whether scarlet fever and diphtheria may be ex- 
cluded with certainty ; as, if they can, it is tolerably certain that the case is 
not one which will give rise to any anxiety either on account of the patient 
himself or his friends. Unfortunately, however, it is not often possible to 
express an opinion without misgivings ; that which appears to be a simple 
tonsillitis may be scarlatinal or diphtheritic in origin. It need hardly be said 
that the child suffering from tonsillitis should be stripped and a careful 
examination made of the surface of the body by a good light in order to 
detect a rash, and the faintest rash would necessarily arouse suspicion. In 
the absence of a rash a certain diagnosis is often impossible, but glandular 
enlargement, discharge from the nose, much yellow exudation on the 
tonsils, true ulceration of the tonsils or soft palate or otitis, if present, would 
make the diagnosis of scarlet fever a probable one. Should desquamation 
follow, if it is certain there has been no rash, it is of no diagnostic importance. 
If nephritis occur in the third week, it points to the scarlatinal nature of the 
attack as beyond doubt. A strawberry tongue is rarely present in the 
absence of a rash. The difficulty of diagnosis between mild diphtheria and 
tonsillitis accompanied by greyish exudation is hardly less than that between 
tonsillitis and scarlet fever in the absence of a rash. Albuminuria, nasal 



Chronic Tonsillitis 69 

•discharge, glandular enlargement and cellulitis, and the presence of Loeffler's 
bacillus in the exudation, all point to diphtheria ; if paralysis follow, the 
diagnosis of diphtheria is certain. (See Diphtheria.) 

Treatment. — Every attack of tonsillitis during childhood should be 
treated not only with respect but with suspicion, and the case should at 
once be isolated as far as it is possible to do so. It should constantly be 
before the mind of the practitioner that the case may be one of abortive 
scarlet fever or diphtheria, and that the nexl case to which he is called in the 
same household may be a genuine attack of one of the above zymotic diseases. 
It is always wise, when called to such cases, to give a guarded diagnosis 
and prognosis until the case has been under observation for a few days. 
The patient is to be confined to his room or to his bed, according to the 
severity of the attack, and his diet should consist of milk, beef tea, and sops. 
If there is much pain in swallowing, hot fomentations medicated with bella- 
donna or opium maybe applied externally and renewed at frequent intervals. 
The tonsils should be painted with a solution of boro-glyceride in water 
(1-12), or iodine gr.ij, glycerine 5j\ an d water 3J ; black currant jelly or 
lozenges are also useful. Salines, such as the citrates or chlorates of the 
alkalies, combined with aconite or salicylate of soda, if there is much fever, 
may be given during the febrile stage ; acids and cinchona during con- 
valescence. 

Chronic Tonsillitis. — So-called chronic tonsillitis, or tonsillar hyper- 
trophy, is a very important child's disease, though by no means limited 
to childhood. The affection consists in an actual overgrowth of the tonsillar 
adenoid tissue, so that the tonsils become greatly enlarged and project as 
rounded or irregular masses in various directions. Most commonly they 
grow inwards towards the middle line, and may reach such a size as to meet 
and be flattened by mutual pressure ; they may then almost completely block 
the orifice of the pharynx. In other instances they enlarge vertically and 
become large oval masses, projecting far down into the pharynx and upwards 
and backwards towards the posterior nares. In other cases again they 
protrude outwards, separating the layers of the soft palate and forming a 
bulging mass on the roof of the mouth. Sometimes the surface is almost 
smooth, marked only by the orifices of the tonsillar crypts, and sometimes it 
is quite rugged and irregular. 

The overgrowth is often accompanied by recurrent attacks of acute in- 
flammation, in other cases there is no pain or acute distress at any time. 
The secretion of the mucous glands may be retained, and thick pellets ot 
inspissated matter be shut up in the crypts. Occasionally, on examining 
the region of the tonsil, instead of the usual appearance, a large yellow mass 
will be seen blocking up the whole of that side of the pharynx : it is soft ami 
fluctuating, and on incision gives exit to a large quantity of thick dibris ot" 
mucus, pus, cholestcrinc, &c. This condition we have sometimes thought 
to be a congenital mucoid cyst. It is rather alarming at first sight, and looks 
like a large abscess on the point ot bursting. The symptoms are those ot" 
tonsillar hypertrophy with more or less dysphagia. 1 

1 The causes of tonsillar hypertrophy are obscure ; it has boon supposed to be the 
result of irritation of neighbouring parts causing enlargement, as in other parts ot" the 
lymphatic apparatus, in some cases possibly Connected with one of the exantheiv. ■ 



yo Diseases of the Digestive System 

The ordinary enlarged tonsil is usually pale, and in old cases hard and 
sometimes almost cretaceous. The enlargement may be found at any age 
from birth (being sometimes congenital) to puberty, or more rarely later ; it 
gives rise to a definite series of symptoms, all or most of which are usually 
present together. There is a vacuous, heavy look, from obstruction to 
breathing and consequent imperfect aeration of the blood, also imperfect 
development, and often stunting of growth ; the mouth is kept open, the 
'breathing is stertorous and in sleep snoring. These children usually sleep 
heavily but restlessly, often starting in their sleep ; incontinence of urine is. 
sometimes present, a result, no doubt, of the supply of imperfectly aerated; 
blood to the nervous centres. There is usually chronic nasal and often 
aural catarrh, from the extension of irritation from the tonsils to the neigh- 
bouring mucous surfaces. The speech is nasal and indistinct, the chest is 
often ill-developed, pigeon-breasted, or, as pointed out by Lambron, has. 
the diaphragmatic constriction (M. Mackenzie). Recurrent acute tonsil- 
litis is generally complained of, but there is seldom constant dysphagia - r 
there is an increase of the pharyngeal mucus due to catarrh, and the breath, 
is often foul. The actual dwarfing and stunting from this condition is some- 
times very marked. We have seen a difference of several months' growth in. 
twins, one of whom had enlarged tonsils, the lost ground being rapidly 
regained after removal of the glands. 

It is in our experience true that enlargement of the tonsils is nearly always 
accompanied by the presence of the closely allied adenoid vegetation in the 
naso-pharynx, to be mentioned presently. Occasionally, however, either 
may exist without the other. The lingual tonsil appears to be much less 
often affected, or at any rate it very seldom gives rise to any symptoms. 
We think it is more common to find adenoid growths without enlargement 
of the tonsils than hypertrophic tonsils without adenoids. 

Treatment. — Chronic tonsillar hypertrophy, when once well established y 
is little affected by mere local applications or constitutional treatment ; it is 
only during an attack of" acute inflammation that good can be done by such 
means. In the early stages of the affection astringents, such as glycerine of 
tannin, and tonics sometimes succeed. The only efficient mode of treat- 
ment is by removal ; caustics and the actual cautery are inferior methods of 
obtaining the same result. 

For that form of enlargement in which the tonsils project inwards, or in- 
wards and downwards, nothing is so efficient, simple, or easy as removal' 
with the guillotine. 1 Chloroform should be given if the child will not allow 
removal otherwise ; there is no objection to it except that it makes the 
operation somewhat more troublesome. 

As much tonsil as can readily be removed should be taken away, but it is 
not necessary to remove the whole gland, the part left behind usually soon 
shrinks. Both tonsils, if enlarged, should, if possible, be removed at one sitting. 

The guillotine cannot be satisfactorily used unless the tonsils project con- 
others perhaps the result of the obstruction of the tonsillar mucous glands ; or, as some 
writers think, it may be a result of the so-called strumous diathesis. 

1 Fahnestock's is the one that we prefer, though it is a somewhat delicate instrument 
and liable to get out of order ; those usually sold are coo large and clumsy for con- 
venient use. 



Chronic Tonsillitis — Tonsillar Calculus yi 

siderably towards the middle line ; in many cases, however, its use may be 
made easier by pressing the tonsil inwards with the ringer applied to the 
neck just in front of and below the angle of the jaw. l Where the overgrowth 
is outwards and the guillotine cannot grasp the tonsil, the vulsellum and 
guarded blunt-pointed bistoury must be used, care being taken to keep the 
edge of the knife turned somewhat inwards. In some few cases even this is 
impracticable, and it is only in these rare instances that puncture with the 
Paquelin cautery should be employed ; the cautery may be thrust through 
the anterior pillar of the fauces, or directly into the gland between the pillars 
at one or two points ; shrinking is said to usually follow. Potassa fusa is some- 
times used, but is dangerous and tedious ; scraping away the tonsils with a 
sharp spoon is the best plan if the gland is very friable and soft. 

Removal of enlarged tonsils while acutely inflamed is usually condemned. 
We have, however, done it with great relief to the patient ; it is, of course, 
much more painful for a few minutes. 

After removal some swelling often follows, and may last for a week or so, 
but soon subsides. After free removal the enlargement rarely recurs. We 
have, however, seen two or three instances where a re-growth, larger even 
than the original one, has appeared after a lapse of some months. We 
should be inclined to look with suspicion upon such cases as possibly indicating 
a tendency to lymphomatous growth elsewhere. 

We have unintentionally enucleated a tonsil with the guillotine on two 
or three occasions, the whole gland coming away entire instead of being cut 
through ; the result was, of course, satisfactory. It has recently been pro- 
posed to revive this old method of enucleation, but we think in the majority 
of cases it will not be found practicable. 

After the operation iced milk only should be allowed for the first day, 
and milk and soft food for the next day or two ; after this the ordinary diet 
may be gradually resumed. Painting the tonsils with glycerine of tannin 
after the operation is perhaps useful. 

We have never seen bleeding follow the operation to any serious extent ; 
when it does occur it usually arises from injury to the pillars of the fauces, 
which are sometimes stretched over the tonsil so tightly as to be indistinct. 
A little ice to suck is all that is needed in most cases ; should there be any 
severe bleeding, pressure or the application of the cautery, or perchloride 
of iron, might be required. Injury to the carotid is, of course, out of the 
question. 

The argument against the excision of tonsils, that the overgrowth subsides 
as the child grows up, is altogether invalid in any severe case, for the mischief 
to the general development, and often to the hearing power, is done before 
the tonsils subside. There is no foundation for the idea that any wasting 
of the testes occurs from removal of the tonsils ; it is much more likely that 
a lack of development would be due to the tonsillar enlargement than the 
reverse. The operation is an altogether harmless and beneficial one. 

Tonsillar Calculus is a very rare condition, due to collection of secretion 
or inflammatory material and subsequent calcareous degeneration ; the tonsil 

1 The tonsil cannot be felt externally, but .1 lymphatic gland lies just on its outer side, 
and when enlarged is often mistaken for the tonsil ( [reves). 



J 2 Diseases of the Digestive System 

is enlarged, hard, and often painful, the calculus can be felt by a probe, and 
should be turned out of its cavity. 

For the connection of tonsillitis with adenitis, the reader is referred to the 
chapter on Diseases of the Lymphatic Glands. 

Enlarged Uvula. — The uvula is sometimes acutely inflamed as part of 
a pharyngitis or chronically enlarged ; in the latter case it may require to be 
snipped off. We have also met with a case of papilloma of the uvula. 

Nasal Adenoid Growths. — It often happens that a child is brought with 
all the symptoms of tonsillar hypertrophy — chronic nasal catarrh, pinched 
nose, nasal obstruction, snoring, nasal voice, deafness, stupidity, &c. {vide 
Chronic Tonsillitis), and yet the tonsils are little if at all enlarged, or if they 
are their removal does not cure the affection. In such cases there is probably 
overgrowth of the post-nasal adenoid tissue, the ' pharyngeal tonsil] or 
* Lnschka's tonsil] so called. This condition, which was first described by 
Meyer, is very common in childhood and is often overlooked ; it is, how- 
ever, readily found out and treated if its symptoms are remembered. 

A finger passed back into the pharynx and turned up behind the soft palate 
to the posterior nares will feel warty, sessile, or pedunculated masses about the 
upper surface of the soft palate and round the posterior nares, often almost 
completely blocking the apertures. 

These excrescences bleed readily, but are not tender to the touch. In 
such cases, scraping the masses away with a Volkmann's spoon passed 
through the anterior nares and guided by a finger in the pharynx, is the best 
treatment. A Meyer's ring scraper or forceps may be employed if preferred, 
or Lowenburg's forceps and Gottstein's scraper will be found useful supple- 
ments to the sharp spoon ; they are of course used through the mouth. It 
is far better in these cases to give chloroform and do the operation thoroughly 
than waste time, and trouble by incomplete scrapings with the finger nail or 
applications of the cautery or other such means. If done thoroughly by the 
method recommended, it is very rarely necessary to repeat the operation, 
though occasionally growths so small as to escape removal subsequently en- 
large and require treatment. It is best to operate with the child's head 
thrown well back over the end of the table, so that no blood trickles into the 
air passages. This operation is one that should be strongly insisted upon ; 
it removes a source of many troubles and much weak health. 

The affection is an exceedingly common one, and may be met with at all 
ages. We have seen it in quite the first few months of life, and we believe 
it is sometimes congenital. No treatment except mechanical removal 
is to be recommended, though the application of caustics may in some cases 
be effectual. 

Pharyngitis Gangrenosa. — We have met with two cases of pharyngitis 
in which extensive ulceration occurred, and which did not appear to be due to 
diphtheria, scarlet fever, or other zymotic disease. One of these cases was 
a hitherto healthy boy aged nine years, there was little fever, but much indura- 
tion and cellulitis at the angle of the jaws. When seen by one of us, it was 
impossible even under chloroform to get a good view of the fauces ; there were 
one or two smart haemorrhages from the mouth presumably from ulceration. 
He was apparently recovering when a sudden haemorrhage occurred, evidently 
from the throat, which proved fatal almost immediately ; no post-mortem was 



Post- pharyngeal Abscess 73 

obtained. In the second case there were no haemorrhages, but a deep 
ulceration of the tonsils and pharynx ; the disease much resembled in its 
onset and course gangrenous stomatitis, and proved fatal. 

Post-pharyngeal Abscess. — Abscess in the prevertebral fascia is 
usually either the result of caries of the cervical spine (see Spinal Disease; 
or of suppuration of the lymphatic glands in this region from irritation about 
the pharynx or posterior nares. The symptoms are dysphagia and dyspnoea, 
with pain and dribbling of saliva or mucus ; a peculiar nasal or palatal 
resonance in the cry is described by Politzer. ' On examination, a soft 
fluctuant swelling will be felt, and the posterior wall of the pharynx will be 
seen to project unduly, and possibly the yellowish colour of the pus ma)' be 
seen through the mucous membrane. When the abscess is due to simple 
mucous irritation it should be opened through the mouth with a guarded 
knife, the child being turned on its face as soon as the incision is made, to 
allow the pus to flow out readily. We have seen post-pharyngeal inflamma- 
tion give rise to so much dyspnoea without any visible pointing as to render 
tracheotomy necessary. Occasionally a large mucous cyst, such as that 
■described as occurring in the tonsil, will be found on the posterior wall of 
the pharynx ; free incision is all that is required for these conditions. In 
other instances suppuration tracks round the outer side of the pharynx 
from the tonsil or soft palate or from suppurating cervical glands or other 
neighbouring parts. Where there is external evidence of abscess it is better 
to make the opening in the neck, so that the wound may be rendered 
aseptic, as in abscess from spinal disease. Other causes of post-pharyngeal 
abscess are injuries and pharyngitis ; it may also occur in the course of scarlet 
fever or be the result of a breaking-down gumma. Many cases are recorded 
by Bokai as idiopathic ; it is not improbable that some of these were 
glandular. Wiel gives otitis as a cause. Convulsions, facial paralysis, great 
swelling of the neck, and spasm of the sterno-mastoid may sometimes occur 
(M. Mackenzie). The disease has been mistaken for many different affec- 
tions, probably most often for croup. Examination of the throat by the eye 
and finger will always clear up a doubt in the later stages, though, as already 
pointed out, the diagnosis may be very obscure at first. 

We have met with these abscesses in quite young infants, as well as in 
older children. In the last case that we saw a finger passed into the abscess 
cavity could find its way between the vertebrae and the pharynx upwards 
nearly to the base of the skull, and downwards almost to the root of the neck. 
The abscess was probably the result of suppuration in a retro- pharyngeal 
lymphatic gland, and caused both dysphagia and dyspnoea. 

Retro-cesophageal abscess sometimes occurs, and may give rise to dyspnoea 
necessitating tracheotomy, rarely to dysphagia ; it may be due to spinal 
caries or extension of suppuration from other parts.'-' It is not so common in 
children as the retro-pharyngeal abscess ; when it occurs there is swelling 
on both sides of the neck, dryness of the throat, tenderness and pain on 
movement, with fever and alteration of the voice. The abscess may burst 
into the (esophagus or burrow round the neck. We have recently met with 
three cases of abscess bursting into the (esophagus : in two caries of the spine, 

1 Jakrbuchf. Kinderheilk. B. \\i. 11. 1. a. 
'-' Ripley, A rchiv of Pediatrics, Feb. 1884. 



74 Diseases of the Digestive System 

and in the other tuberculous gland disease was the cause of the abscess. 
According to Barthez and Rilliet, a form of dry coryza, with even coma or 
convulsions, may occur, and the onset may be sudden. After the abscess 
has burst, ' traction diverticula,' or stricture of the gullet, may result. The 
prognosis is bad. Fomentations and feeding by enemata or an oesophageal 
tube should be the early treatment, with incision at the posterior border of 
the sterno-mastoid as soon as there is distinct evidence of suppuration. 

Stricture of (Esophagus. — Apart from congenital malformations, 
oesophageal obstruction in children is due either to paralysis, or to cicatricial 
strictures, resulting usually from swallowing hot or corrosive liquids, such as 
potash, hydrochloric acid, &c. In such cases there is immediate danger of 
suffocation from implication of the larynx, as well as more or less dysphagia 
from pain and swelling. These troubles, however, may be slight and tran- 
sient, and yet after a time cicatricial. stricture may appear, or the obstruction 
may persist from the first. 

In cicatricial strictures there is a good deal of muscular spasm present,, 
either constantly or from time to time, and this may be much increased by the 
passage of bougies. In some cases it is impossible to pass even a small in- 
strument without an anaesthetic, and yet a fair- sized one may be admitted when 
the child is fully under chloroform. Sometimes at intervals the child is able 
to swallow fairly freely, while at other times the obstruction is almost com- 
plete. The profuse secretion of saliva and mucus is often very distressing. 
The most common seat of such contractions is high up in the gullet, but they 
may be very extensive. The position of the stricture may be ascertained by- 
auscultation during drinking, or by the passage of bougies, 1 after the history 
of the accident and the dysphagia have led to the discovery of the obstruc- 
tion. A careful examination should be made of the oesophagus, to find out 
if possible the calibre, position, and number of the strictures, but bougies 
must be used with the utmost gentleness. We have had a case of perforation 
of the oesophagus and escape of fluid into the pleura in our own experience. 
In a case which we saw with Mr. T. H. Pinder he told us that at one time 
marked improvement in power of swallowing followed entire deprivation of 
all food by mouth ; the child was supported for some days entirely by 
enemata, and it is probable that absence of irritation caused relaxation of 
muscular spasm, though there was a possibility that the relief was due to a 
sloughing off of the edge of the constricting cicatrix at least in part, or it 
may have been merely that there was an interval in the progress of the con- 
traction analogous to that occurring in cases of malignant disease. Mr. Pinder 
suggested that abstinence might also have diminished the size of the pouch 
which forms in these cases above the stricture, and so abolished the valve- 
like obstruction to some extent. 

The best treatment of oesophageal stricture in such cases is usually that 
by gradual dilatation with bougies.' 2 The drawback to it is that relapse is 
very apt to occur as soon as the daily passage of the instrument is omitted. 
Forcible dilatation by MacCormac's dilator and internal cesophagotomy have 

1 In new-born children the distance from the gums to the cardiac orifice is about seven 
inches (Sir Morell Mackenzie). 

2 Keller records thirty- five cases under two years of age with twenty-three cures, im- 
provement in three cases, and five deaths, four remaining under treatment. 



Swallowing Foreign Bodies 75. 

been employed ; the former may be useful, the latter is too dangerous. Fail- 
ing these, cesophagostomy may be performed if the stricture is limited to the 
upper part of the gullet, or if not, gastrostomy ; the latter operation is the 
safer and the more generally applicable one. If an operation is to be done, 
it must not be put off too long. As soon as it is clear that dilatation is insuf- 
ficient and the child is losing weight, no further time should be wasted. 
Done early, and done in two stages (Howse), some success may be expected 
from gastrostomy, and the rest given to the gullet by the operation may 
result in restoration of the canal subsequently (Davies Colley), or it may be 
possible to dilate or divide the stricture by instruments passed upwards 
from the stomach into the oesophagus. For details of the operations we 
must refer to the general text-books. In a recent case in which we performed 
gastrostomy there was much trouble from regurgitation of the food through 
the gastric fistula. The wound became unhealthy, and the child died ot 
abscess between the liver and stomach. 

(Esophageal stricture from congenital syphilis, and obstruction from 
pressure of abscesses outside the gullet or from traction by cicatricial tissue 
around (pericesophageal abscess), are occasionally met with, as in the follow- 
ing case, in which stricture of the oesophagus followed scarlet fever : 

Hannah N. , aet. three, had scarlet fever six months before admission. The attack- 
was a severe one, with a bad throat and suppuration of cervical glands. She was admitted 
April 4, 1892, with stricture of the oesophagus, severe enough to have prevented swallowing 
solids for some time past. Takes milk and gruel. The obstruction was at the level of the 
cricoid, and even the smallest bougie could not be passed through it. The pharynx above 
the stricture was dilated, causing a protrusion on the left side of the neck. She was able 
to swallow milk and fine sop, and gained weight in hospital. She was taken out, and 
again admitted in the following October, when the symptoms, which had been better, 
became worse upon attempting to swallow some apple. There was then complete 
obstruction, but under chloroform a small catheter (No. 3, English) was passed through 
the stricture, which was apparently extended for a considerable distance. When heard 
of two years afterwards, she could eat bread and butter and mashed potatoes very well, 
but could not get down meat. She was well nourished. 

Swallowing Foreign Bodies. — It is very common for children to be 
brought with a history of having swallowed a farthing or button, or some- 
thing of the kind, and much alarm is caused to the child and its friends. 
In many cases the history is a mistaken one, in others the foreign body 
passes into the stomach, gives rise to no symptoms, and is voided in a day 
or two with the motions. 

The only treatment required in such cases is to give the child plenty of 
bread, potatoes, suet pudding &c. to provide a sufficient faecal sheathing for 
the harmless passage of the body. 

In some few instances, however, an angular mass such as a bone, or some 
sharp-pointed object as a pin, may be swallowed, and may be arrested in the 
pharynx or oesophagus. In such cases there is usually some obvious sign of 
its presence, such as pain, dysphagia, retching or vomiting ; possibly some 
blood-stained mucus is brought up. 

If there is no urgent dyspnoea, a careful examination of the fauces should 
first be made, to see if the object is not lodged between the pillars ; failing 
this, the finger should be passed to the back ot" the throat, and the root of 



7 6 Diseases of the Digestive System 

the tongue and epiglottis be searched, care being taken not to mistake the 
cornua of the hyoid for a foreign body. If nothing is found, and the site of 
the body can be felt from the outside of the neck, and especially if the mass 
is hard, angular, and insoluble, an attempt should be made to remove it 
Avith the bristle probang or coin catcher, or failing these, possibly with 
oesophageal forceps, though these are more dangerous. Failing these plans, 
the choice lies between an attempt to push the foreign body on into the stomach 
and the performance of cesophagotomy. The first plan should be followed in 
the majority of cases, and can be best managed by the gentle, steady use 
of a good-sized bougie. It is applicable to instances where the foreign body 
is soft, smooth, and rounded, and not likely to give rise to trouble in its pas- 
sage through the intestines. It must be remembered that a feeling of soreness 
and irritation may remain about the fauces for some time after the passage 
and removal of a foreign body, and may give rise to the belief that there is 
still something there. In cases of swallowing fish bones, and their becoming- 
impacted, doses of hydrochloric acid or vinegar and water may be given, 
but the remedy is unpleasant and tedious. An anaesthetic may be used to 
lessen the discomfort of examination. Emetics, as a rule, are not good 
treatment. 

CEsopliagitis. — Infantile oesophagitis, first described by Billard, is a rare 
disease, supposed to be caused by irritation from bad milk, improper feeding, 
or sore nipples. The symptoms are unwillingness to suck, crying and im- 
mediate regurgitation after beginning to suck, and often some tenderness 
about the neck on pressure. The inflammation maybe local or general, and 
may give rise to ulcers or sloughing, and possibly to subsequent stricture. 
The prognosis is bad ; the disease may come on immediately after, or even 
exist at birth. It is not likely to be mistaken for anything except congenital 
malformation, in which the obstruction is absolute. Cleanliness, careful 
feeding, and the administration of glycerine of borax in small doses, con- 
stitute the treatment. 1 

Other rare conditions met with are congenital hypertrophy of the mucous 
^glands and varix of the oesophagus. 

1 Sir Morell Mackenzie 



77 



CHAPTER V 

DISEASES OF THE DIGESTIVE SYSTEM {continued 

Examination of the Abdomen. — Inspection. — The abdomen in infancy 
is proportionately larger and is usually more distended than the abdomen 
of adults, and this is at once apparent on inspection as the infant lies stripped 
in its cot or on its mother's lap. An exaggeration of this condition is often 
seen in cases of chronic dyspepsia or intestinal catarrh ; there is great 
distension of the intestines with ' bound wind,' the abdomen being much 
increased in girth and the skin stretched and shiny. If, as is often the case, 
there is more or less wasting of the fatty tissues, the large abdomen con- 
trasts strangely with the wasted and shrivelled form of the infant, giving it a 
very characteristic appearance. The large liver of the infant is responsible 
to some extent for the disproportionate size of the abdomen. An inspection 
of the abdomen will reveal any enlarged veins on the surface, or the 
presence of large tumours or an excessive amount of fluid in the peritoneum. 
The umbilicus will be examined at the same time, and any hernia or local 
lesion here detected. Instead of a distended abdomen, the condition of 
flatness or retraction may be present, especially if there is acute cerebral 
disease. 

Palpatio?!. — The muscular wall of the abdomen is comparatively thin. 
and less rigid in infants and young children than it is in adults, and con- 
sequently palpation yields more certain results, and is of greater value as a 
means of diagnosis in the former than in the latter. Thus in young children 
the edge of the liver, an enlarged spleen or kidney, faeces in the colon, a dis- 
tended bladder, a matted and thickened omentum, and even enlarged 
mesenteric glands may be felt by more or less deep pressure by the hand on 
the abdomen. It is needless to say that the conditions are not always 
favourable; distension of the intestines with gases so as to bulge and distend 
the abdominal walls will necessarily interfere with palpation of the abdomen : 
then, again, a fractious and crying child is necessarily difficult to examine in 
this way. But even under the most unfavourable circumstances, the warm 
hand, laid on the abdomen and firmly pressed in, may detect a tumour or 
some enlarged organ, and information be gained which may be oi great 
advantage in making a diagnosis. Even ascertaining the tenseness or laxity 
of the abdominal walls is of importance in forming a diagnosis between 
cerebral and gastric vomiting, as in cerebral disease there is mostly a relaxed 
state of the walls of the abdomen which enables the edge o\ the liver and 
perhaps other organs to be felt with abnormal distinctness : while, on the 



7 8 Diseases of tJie Digestive System 

other hand, in gastro-intestinal disorders there is usually more or less disten- 
sion of the stomach and bowels, the distended organs interfering with a 
thorough exploration of the abdominal contents. Palpation may give 
valuable information with regard to pain and tenderness in the abdomen, 
provided the observer is alive to the fallacies which may arise through the 
fractiousness of his little patient. 

By percussion the investigator is able to confirm the results obtained by 
palpation, and gain information not otherwise obtainable ; thus he may map 
out by percussion the outline of a dilated stomach, or ascertain the limits of 
fluid in the peritoneum. 

Anatomically the abdomen of the infant differs from the adult's in that 
the liver is proportionately larger in the newly born infant, occupying at 
least half of the abdominal cavity. The inferior limit of the liver is con- 
sequently lower, and the left lobe covers the stomach to a greater extent in 
the infant than in the adult. The infant's stomach, so far as shape is con- 
cerned, does not differ in any important respect from the adult's ; the cardiac 
curvature is perhaps less well marked, and it comes into closer relation with 
the liver and spleen. As a consequence of the thinness of their walls, the 
stomach and intestines are apt to become dilated during infancy from the 
pressure of gases given off from their contents, and to remain more or less 
constantly in a distended state. The large intestines — more especially the 
caecum, ascending colon, and sigmoid flexure — are more movable, and con- 
sequently more easily dragged from their normal position, in infants than in 
adults. 

This is especially true of the sigmoid flexure ; for sometimes at an 
autopsy the sigmoid flexure, if distended with gas or faeces, may be found 
much displaced towards the right side. This must be remembered in pal- 
pating the abdomen, for faeces which from their position may appear to be 
in the ileum or caecum may in reality be in a displaced sigmoid flexure. 

The Dyspeptic Diseases of Infancy and Childhood. — No infant, 
whether fed at the breast or with artificial foods, escapes having indigestion 
in one form or another ; various dyspeptic ailments are certain sooner or 
later to supervene and form no insignificant part of the troubles of an infant's 
life. We have not far to go to seek an explanation of this. The alimentary 
canal of an infant is exceedingly intolerant of any form of irritation, while, 
-with very slender resources to fall back upon, it has to perform a large 
amount of work in the digestion of food in order to make good the losses 
incident to life and supply suitable material for the rapid growth which is 
taking place. During the whole of infancy the digestive apparatus is worked 
to its uttermost capacity in digesting the food required for the infant's main- 
tenance and growth, and any overtaxing of its powers is very likely to be 
followed by disturbed function. The commonest causes of indigestion 
in infancy are practically the same as those in adults, the appetite perhaps 
is in excess of the digestive powers, and more food is taken than can be 
digested, or the food taken is of an improper quality ; in both cases the 
result is the same, the presence of decomposing food in the alimentary canal 
giving rise to vomiting, flatulence, and diarrhoea. In some cases the 
vomiting points to the stomach being most affected ; in others the passage 
of loose stools containing undigested food, with much flatulence, indicates 



Flatulence and Colic — Vomiting 79 

that the small intestines are involved, the large bowel when colic, tenesmus, 
and an excoriated condition of anus are present. Before long a catarrhal 
condition of the mucous membrane is set up, or in the milder cases perhaps 
there is a deficient secretion of the digestive juices, or they are impaired in 
quality so that the food taken undergoes decomposition, irritates the bowels, 
and leads to its being quickly expelled instead of undergoing the normal 
process of digestion and absorption. In discussing these dyspeptic condi- 
tions arising during infancy and childhood, it is convenient to consider the 
prominent symptoms separately, always bearing in mind, however, that they 
are only symptoms of morbid conditions and not diseases. 

Flatulence and colic may be present unaccompanied by either vomit- 
ing or diarrhcea, both breast-fed and bottle-fed babies alike suffering, though 
the latter do so more frequently. It is the result in many instances, perhaps 
most frequently, of the infant taking its food too quickly and in too large quanti- 
ties ; digestion is performed imperfectly, decomposition in the small intestines 
ensues, and gases are formed which distend the bowels. The abdomen is 
distended, the infant is restless and cannot sleep, it is constantly crying and 
tossing about, and if it brings up or passes large quantities of flatus, there is 
much relief. Ease for the most urgent symptoms may be found in giving the 
infant a teaspoonful or two of an equal quantity of lime water and cinnamon 
water, or small doses of carbonate of ammonia and soda in peppermint 
■water, or a small piece of the compressed salts known as ' soda-mints,' 
■dissolved in a little syrup. It will be necessary, temporarily at least, to 
lessen the amount of food which the infant is taking ; this can be done in 
breast-fed children by giving them some sweetened barley w r ater or whey 
before taking the breast and not allowing the breast to be given for too long 
or too often. In artificially fed infants the amount of food, especially the 
amount of curd, must be reduced either by dilution with barley water, lime 
water, or by predigesting the curd. Large enemata of warm water 
(10-15 oz an d hot fomentations to the abdomen will generally relieve the 
severer cases of colic due to flatulence, and a grain of mercury and chalk 
powder combined with half a grain of Dover's powder may be given by the 
mouth. Carbonate of magnesia with syrup of ginger is often useful. 

Vomiting-. — Vomiting is a very common complaint for which medical aid 
is sought. That this vomiting is readily brought about is hardly to be 
wondered at when it is remembered with what vigour an infant will suck, 
and yet the stomach of a newly born infant cannot hold more than a wine- 
glassful of fluid without being over-distended, and that, moreover, during 
digestion active peristaltic movements take place. The most frequent way 
in which food is rejected from the stomach is what is termed by mothers 
1 posseting,' which consists of eructations of small quantities of fluid from 
time to time without any effort, the food escaping from the corners ot the 
infant's mouth in consequence of a too vigorous peristaltic action of the 
stomach. Fluid will also frequently regurgitate during the eructation oi 
gases from the stomach. In true vomiting there is more or less retching, and 
the contents of the stomach come up with considerable force. The most fre- 
quent cause of this is an irritable condition o( stomach due to .1 catarrhal state 
of the mucous membrane, the curdling ferment is abnormally active, while 
the digestive ferment is present in smaller quantity than usual. Vomiting 



8o Diseases of the Digestive System 

is especially common in infants who are taking cow's milk, and who are 
unable to digest the large quantities of hard curd contained in the milk, 
the stomach probably containing much decomposing curd and mucus. 
Sometimes the vomiting is the result of over-distension, or the formation of 
excessive quantities of gases, or of coughing. The vomiting of breast-fed 
infants is often due to their being given the breast at too frequent intervals, 
or to some other cause, as the ingestion of unsuitable food on the part 
of the mother ; or she may be suffering some great anxiety, which is in itself 
quite sufficient to cause an alteration in the quality of the breast milk. 
Vomiting may be the result of some congenital or acquired obstruction of 
the bowels. It must also be borne in mind that vomiting in infants and 
children is frequently reflex, and not due to any lesion of the stomach, but 
the result of cerebral disease, as meningitis, or tumour, or of the irritation 
caused by cutting a tooth. Vomiting is sometimes the first, and for a time 
the only, symptom in tubercular meningitis, and may precede for a week, or 
even longer, any marked cerebral symptoms. Reflex vomiting may at first 
be entirely undistinguishable from dyspeptic vomiting ; the condition of the 
tongue is no certain guide, and it is only as the cerebral symptoms become 
more marked, the abdominal walls either retracted or in a toneless, flabby 
condition, that a diagnosis can be made. In older children the vomiting of 
an acute gastric catarrh may last for a few days, but any long-continued or 
habitual vomiting is very suspicious of cerebral disease. Hysterical vomiting 
is occasionally seen in girls about puberty. Vomiting is usually an early 
symptom of scarlet fever and also of influenza. 

The treatment of vomiting must necessarily depend upon its cause. 
Vomiting in the breast-fed infant, provided the mother's manner of life or diet 
is not at fault, is probably the result of too large quantities of milk being 
taken and it will generally be sufficient to insist upon regular hours of feed- 
ing at not too frequent intervals, and to give the infant a few teaspoonfuls of 
sweetened lime water before it has the breast, with a dose or two of hyd. c. 
creta to act on the bowels. Vomiting in the bottle-fed infant is more difficult 
to deal with, especially when a gastric catarrh exists. The infant is under 
these circumstances very intolerant of cow's milk, even when largely diluted, 
the milk being quickly curdled by the acid mucus in the stomach, and the 
hard lumps of curd are vomited in masses. In the milder cases of vomiting 
in infants, it may probably be sufficient to resort to dilution of the milk with 
barley water in the proportion of one-third to two-thirds of the latter, or to the 
use of Mellm's Food. Sterilised milk and condensed milk or desiccated milk, 
if properly diluted, are nearly always retained more readily than fresh cows 
milk by infants who vomit. Whatever food is resorted to, great care must 
be taken that too large quantities are not given at a time or taken too 
quickly. In severer cases, where no form of fresh milk is tolerated, milk 
peptonised by the addition of Benger's peptonising powders, or the condensed 
peptonised milk sent out in tins by Savory & Moore, are frequently useful, and 
are retained when no other form of milk is tolerated. If the vomiting is 
severe and continued, the bottle must be done away with and the infant fed 
by the spoon, or a wet nurse may be obtained. In some forms of severe 
vomiting there is an inability to retain any form of milk, and veal broth or 
barley water must be reported to for a while at least. An alkali, such as car- 



Diarrhoea 8 1 

bonate of soda, with two or three grains of pepsine in powder, may be given 
before meals, and is often of use ; or bismuth and nux vomica may be 
given. (F. 5.) Washing out the infant's stomach is often a useful expedient ; 
the infant ceasing to vomit after acid mucus and decomposing curd have 
been washed out. 

Diarrhoea. — Looseness of the bowels is symptomatic of many different 
disorders and morbid conditions. An attack of diarrhoea frequently ushers in 
scarlet fever, or may be present in all stages of the malignant form ; it may 
accompany typhoid fever ; it is often present in septicaemia, empyema, 
uraemia, peritonitis. The commonest form in children is the result of 
an accumulation of undigested food in the intestines, or of some irritating 
matters taken in the food. Infants at the breast are liable to suffer from 
looseness of the bowels soon after birth on account of the colostrum not 
agreeing with them ; they are also liable to suffer from the taking of im- 
proper food on the part of the mother during lactation ; over-feeding or a 
fit of anger, or other strong emotion on the part of the mother, has been 
known to be followed by diarrhoea in the infant. Artificially fed infants 
are much more liable to suffer than infants at the breast. The difficulty 
with which the curd of cow's milk is digested overtaxes the digestive 
powers, the undigested curd irritates the bowels, and increased peristalsis 
is set up. An intestinal catarrh is soon established, the infant is restless, 
peevish, and cannot be got off to sleep, the abdomen is distended with gas, 
the legs are drawn up, and the infant passes perhaps five or six stools or 
more per diem. 

An examination of the napkin shows, instead of the bright yellow homo- 
geneous stools of the healthy infant, curdy flakes or other undigested food, 
and a greenish slimy liquid which stains the diaper. The infant is thirsty, takes 
the breast or the bottle vigorously at first, but is soon satisfied and pushes it 
away when offered. The tongue is coated and the mouth is often the seat 
of aphthous stomatitis. Vomiting may be present, but is mostly absent. In 
a day or two the infant begins to waste, the muscles of the limbs grow flabby, 
and the skin hangs about the thighs in loose folds, and the parts about the 
anus and genitals become red and frequently raw. In most cases improve- 
ment takes place after a few days ; the stools become more normal and the 
infant quickly recovers. Some infants are liable to such attacks especially 
during hot weather, and the final result may be a more or less chronic con- 
dition of catarrh, to end finally in general malnutrition from gastro-intestinal 
atrophy. Rickets is a very frequent sequence of intestinal catarrh. 

Not infrequently the symptoms point to a catarrh of the large bowel, and 
are more of a dysenteric character. Dysenteric diarrhoea may be primary, 
or follow an attack of simple diarrhoea, the general affection passing away 
and leaving a local inflammatory condition in the colon, sigmoid flexure, and 
rectum. The same form of diarrhoea frequently succeeds whooping cough 
and measles. There is distension of the abdomen, with often more or less 
tenderness in the left iliac region on pressure, frequent passage of small 
liquid stools, consisting largely of mucus, biliary matters, and perhaps blood, 
preceded by much straining and forcing down and frequently followed by 
prolapse of the rectum. Older children often suffer from this form of catarrh 
of the large bowel, passing lumpy mucoid stools, and getting up perhaps 



82 Diseases of the Digestive System 

several times in the night to sit on the vessel, only passing each time a little 
mucus streaked with blood. Dysenteric diarrhoea is apt to become chronic, 
alternately better and worse, until the patient is reduced to a condition of 
wasting. 

Sometimes dysenteric diarrhoea occurs in epidemics in winter as well as 
in summer. We have known several such epidemics. 

Older children sometimes habitually suffer from what has been termed 
' lienteric ' diarrhoea, in which a loose stool is apt to follow the ingestion of 
food. Such children are generally subject to loose bowels, a diarrhceal stool 
following any form of excitement, especially a fright, the immediate cause 
being an exaggerated peristaltic action of the ileum and colon. There is 
often in such cases a catarrh of the large bowel, as evidenced by the excess 
of mucus which they pass : phthisical children also may suffer in this way. A 
form of diarrhoea which has been termed ' fat diarrhoea,' from the presence 
of an excessive quantity of fat in the stools, has been described, which is 
presumably due to catarrh of the duodenum and pancreatic duct. 

In the slighter forms of diarrhoea in infants, where there is not much 
restlessness, distension of abdomen, and not more than four or five loose 
stools during the day, it will be usually sufficient to underfeed them for a day 
or two, and give them some mild laxative, as castor oil or hyd. c. creta, and 
a simple alkaline mixture. Infants at the breast may be given a few tea- 
spoonfuls of sweetened barley water in lieu of the breast, or after they 
have been partially satisfied at the breast. Bottle-fed children should have 
their milk more diluted than usual, or a mixture of cream and barley water 
may be substituted for the milk. 

If the purging is at all severe and curdy masses are vomited, or appear in 
the stools, it will be best at once to withhold all milk for a day or two, and to 
substitute some more digestible and less fermentable food. Peptonised milk 
will sometimes answer very well in the less severe forms of diarrhoea, but it 
must be borne in mind that in any given case much of the curd remains un- 
converted into peptones, and the unchanged curd may often be seen in large 
quantities in the stools, even where great care has been taken in the pepto- 
nising of the food ; peptonised milk is of more service in gastric catarrh and 
vomiting than in acute diarrhoea. In the severer cases, where the stools 
are frequent, the blandest and most unirritating foods must be given ; such, 
for instance, as — 

Arrowroot water .2 ounces 

Whey 2 „ 

White sugar 1 teaspoonful. 

or — 

Barley water . . . ... . .10 ounces 

White of egg £ ounce 

White sugar . . . . . . 1 or 2 teaspoonfuls 

Either of these may be given out of a bottle every few hours, and in amounts 
according to age. Veal broth is also very useful. 

The medicinal treatment in the early stage consists in giving a laxative 
for the first twelve or twenty-four hours. In these cases the diarrhoea is 



Constipation 83 

probably the result of a congestion of the mucous membrane of the intestine, 
and of the presence of irritating, perhaps putrescent materials, and it is wiser to 
.assist elimination than attempt to prevent it by means of opium or astringents. 
To this end emulsion of castor oil or small doses of calomel (£ to \ grain) 
may be given, the latter being preferable if there is vomiting, on account of 
its being more readily retained by the stomach. (F. 6.) 

By the end of twenty-four or forty-eight hours the laxative will have done 
all that can be expected of it, and the stools will be yellow, homogeneous, 
.and less frequent. A sedative may now be useful, such as bismuth or zinc. 
(F. 7 and 8.) 

In the majority of cases of simple diarrhoea the attack is arrested by these 
means — namely, a liquid diet in which milk is excluded or given sparingly, 
and a laxative for a day or two followed by bismuth or zinc. It not unfre- 
quently happens, however, that a simple diarrhoea without urgent symptoms 
passes suddenly into the acute or inflammatory form, or, on the other hand, 
it may end in a more or less chronic condition of looseness of bowels with 
marked loss of flesh. 

As improvement takes place, milk diluted with whey or Mellin's Food may 
be allowed in small quantities, or, what is useful and readily prepared, milk 
diluted with twice its bulk or an equal quantity of arrowroot water (a tea- 
spoonful to 10 oz.) and sweetened with white sugar. Malt extract may be 
added a few minutes before the food is taken. During convalescence, diluted 
acids with pepsine or astringents are the best remedies. (F. 9 and 10.) 

Constipation. — Constipation is one of the minor troubles which are of 
most frequent occurrence during infancy, and for which the advice of the 
practitioner is sought. Both breast-fed and artificially fed infants suffer, 
though the latter far more frequently and severely than the former. The 
healthy infant passes two or three semi-liquid homogeneous orange-coloured 
stools daily without effort or straining, while some infants appear to have a 
difficulty in defecation from want of expelling power, but at once pass 
a fairly healthy stool if the colon is reflexly stimulated by inserting a small 
suppository into the rectum. In the majority of cases, however, in which 
•constipation exists, the stools are dry and pale with an excessive quantity of 
mucus, and an evacuation only occurs once a day, or perhaps once every two 
or three days. There is usually much straining before the stool is passed, 
and perhaps some mucus tinged with blood may accompany or follow the 
stool. Infants who suffer much from constipation are usually weakly, 
anaemic, and dyspeptic, but they arc by no means always badly nourished 
.as far as fat is concerned. Rickety children during their second and third 
years mostly suffer more or less from constipation. 

It must be borne in mind that constipation is only a symptom, ami may 
be the result of grave cerebral disease, or there may be some congenital 
malformation of the intestine. In the majority of cases it is the result of 
a want of tone in the large bowel, which in chronic cases may be dilated, 
the peristaltic action being sluggish and not easily evoked ; while the intestinal 
juices are scanty and the bile deficient in quantity. Mucus appears in these 
children to be secreted in excess. There is apparently also a deficient 
digestion of the curd of milk, the faeces contain an abnormal quantity of 
solid matters which accumulate in the colon as it is powerless to expel 



84 Diseases of tlie Digestive System 

them. In some cases constipation is due to a deficiency of fat in the food,, 
the faeces normally contain fat, and it appears to act as a natural purgative- 
Fluid fasces in the colon seem much more readily to excite peristalsis 
than solid faecal matters. Infants who are constipated usually have ab- 
normally distended abdomens, and faecal masses may often be felt in the 
transverse and descending colon. In some cases constipation is distinctly 
hereditary ; mothers who suffer much from this trouble often have infants who 
also suffer in this way. It seems likely that in some instances the mothers 
or nurse's milk may be poor in quality, and especially deficient in fat, and 
there may in consequence be a small amount of faecal matter. It must not 
be forgotten that narcotics in small doses constipate, and bromides — though 
in less degree — have the same effect. 

It is needless to remark that constipation is a frequent trouble not only 
in infants, but also in both young and older children. Fat, rickety children., 
who are late in walking, very frequently suffer in this way. In some, con- 
stipation and looseness of bowels alternate with each other. It mostly, 
perhaps, occurs in those children where milk in too large quantities is given 
and is not well digested, as evidenced by the large solid pasty stools. In 
older children it occurs in those who take little exercise, and who have large 
appetites ; though in some of these cases it appears to be hereditary. If an 
infant at the breast suffers from constipation, care should be taken to first 
inquire into the diet and habits of the mother or wet nurse. An analysis of 
the milk maybe made to determine the amount of fat, it may be necessary for 
the mother to take more in the way of stewed fruits or some laxative medicine, 
such as confection of senna or cascara. In some cases the infant's stools may 
be fairly normal, and the infant appears to suffer from a want of expelling 
power ; this may be overcome by gentle friction of the abdomen with the 
oiled hand, or it may be necessary to reflexly stimulate the colon and ab- 
dominal muscles by introducing into the rectum a small soap or other sup- 
pository, or a few drops of glycerine and water. In artificially fed infants of 
feeble digestive powers, treatment is often much less successful. The first 
consideration is the diet ; this will probably have to be changed in the direc- 
tion of diminishing the quantity of curd, increasing the amount of fat, and 
adding some form of malted food or extract of malt. Oatmeal water, or a 
small quantity of finely ground oatmeal added to each bottle, may have the 
desired effect. Persistent and carefully applied massage to the abdomen by 
a trained nurse is of much value in obstinate cases of habitual constipation. 
Enemata of glycerine and water (5ss-5j) or olive oil are preferable to medi- 
cines for habitual use. Glycerine suppositories are often successful. Bitter 
and nauseous medicines are to be avoided as far as possible, for it is more 
than likely they will not be persevered with by the nurse or friends. In slight 
cases five to ten grains of the old-fashioned manna, or a teaspoonful or two of 
fluid magnesia, may be added to the food as often as is necessary, but it is 
more than likely both of these remedies will have been tried by the friends 
before medical advice is sought, and indeed they will only be of service in 
slight and easily overcome constipation. When these fail, small doses of 
calomel {\-\ grain) twice a day for a few days will, if aided by enemata, often 
succeed in bringing about a more satisfactory state of things, for a while at 
least. The fluid extract of cascara in five to ten minim doses made into a. 



Acute Gastric Catarrh 8$ 

cordial with tr. and syrup of orange peel is often useful for continued use ; 
liq. jalapas res. or injectio glyc. jalapae res. may be of service. We have 
often found liq. helaline and pepsine or liq. euonymin and pepsine in 
15 to 20 minim doses very useful in the constipation of infants and children. 

In older children the diet must be carefully regulated ; pastry, salt meat, 
and sweets must be forbidden, while oatmeal, green cooked vegetables, 
stewed fruit, orange juice, stewed prunes and figs, may be given with dis- 
cretion. Sponging with cold water in the morning, plenty of outdoor 
exercise, and only a moderate amount of brain work, should be insisted on. 
Of medicines, the most efficacious are some of the mineral waters, such as 
Rubinat, ^Esculap, Franz Josef, given in warm water or milk overnight or the 
first thing in the morning. Granules containing \ grain of aq. extract of 
aloes or calomel \ grain, with ex. coloc. co. f grain, are useful ; or \ grain of 
res. podophylli. But we frequently find in practice that children will neither 
take mineral waters nor granules, and we have to fall back on such drug 
sweetmeats as cascara chocolate bonbons, or ' tamar indien ' lozenges, which 
aie pleasant to take, and in some instances at least very effectual. 

The B. and \V. tabloids of cascara or cascara comp. or bi-palatinoids 
(Oppenheimer) of sulphate of iron and aloes or cascara are readily taken by 
older children. In anaemia with constipation the old-fashioned mixture of 
ferrous sulphate and mag. sulph. is very efficacious, but nauseous. (F. 11.) 

Acute Gastric Catarrh 

If a child is suddenly attacked with vomiting and high fever, the 
probability is strong that 'he symptoms are due to the onset of some zymotic 
disease, such as scarlet fever or epidemic influenza, or to gastric irritation. 
In infants the symptoms may indicate the onset of the so-called ' cholera 
infantum,' or zymotic diarrhoea. It is, of course, quite possible that the 
vomiting and fever may be clue to a chill ; but it is far more likely to be the 
result of some serious error in diet. In any such case, inquiry must be 
made as to the food the child has taken during the few hours preceding the 
attack, as well as to the possibility of a scarlet-fever infection, and the throat 
and skin must be carefully inspected. In some children there is a special 
liability to the so-called bilious attacks, which are in all probability really 
attacks of acute gastric catarrh. There is headache, nausea, vomiting, and 
fever ; the stomach may reject first some undigested food, then more or less 
bile-stained fluids. In a few clays the attack passes oft", and the child is 
perhaps better in health than it was before the attack, the vomiting and 
thorough emptying of the stomach having had a distinctly salutary effect. 

In some cases of acute gastric catarrh there is constant and uncontrollable 
vomiting for some clays. 

In acute gastro-enteritis, the result of taking some toxines from meat or 
milk, the vomiting, colic, and diarrhoea are often excessive, 

In all cases of acute gastric catarrh it is important to give the stomach 
a temporary rest by avoiding all food or fluids, ami giving a little ice by the 
mouth till the vomiting ceases. Rectal alimentation may be resorted to if 
necessary. Veal broth and peptonised milk are the most likely foods to be 
retained by the stomach, but it is not wise to attempt to give (ood by the 



86 



Diseases of the Digestive System 



stomach too soon. Small doses of calomel are useful if the bowels are 
confined ; dilute hydrocyanic acid and antipyrin are also useful in checking 
the vomiting. 



Acute Gastro-intestinal Catarrh. Inflammatory or Zymotic 
Hiarrhoea. Cholera Infantum 

With the commencement of the warm weather in June or July there is 
an increase in the number of cases of infantile diarrhoea ; and by the time- 
the end of July or the beginning of August is reached— especially if the 
weather is close and dry — there is tolerably certain to be, in large cities, an 
epidemic prevalence of diarrhoea. It must be within the experience of all 
that the diarrhceal diseases are commoner in summer than in winter, and,, 
moreover, that there is more diarrhoea in a hot dry summer than in a 
cold and damp one. The following figures show these facts in a forcible 
manner ; they are taken from the records of the Children's Dispensary,, 
Manchester : x 

Monthly Admissions of Cases of Diarrhoea for the year 1880. 



- 


No. of cases 


Mean lowest 
No. of deaths and mean highest 
temperature 


January 
February 
March 
April . 
May . 
June . 
July . 
August 
September 
October 
November 
December 








12 

24 

19 

26 

19 

45 
89 
362 
264 
62 
18 
13 




— 26-41 F. 

— 34-52 

— 34-57 

1 37-59 

— 39-64 

2 47-72 
4 52-72 

33 55-75 
43 51-73 
13 37-58 

— 28-53 
33-52 


Total 








953 96 



These figures show that there are at all times of the year a certain 
number of cases being brought for medical aid on account of diarrhoea, 
the number being fairly constant during the first five months and the 
last two months of the year ; with the warm weather of June the number 
increases, reaching its maximum in the hottest weather of August, then 
declining to the normal number in the last two months of the year. The 
year 1880 was a more than usually hot summer for this country, but other 
years show the same relations between the diarrhceal disease of the winter 
and summer months, though in cooler summers the disproportion is not so- 
great. 

1 By ' diarrhoea ' are meant those cases in which diarrhoea was a prominent symptom- 



Zymotic DiarrJicea 87 

The same story is told by the mortality tables of diarrhoea in Berlin 
(Baginsky), in New York (Siebert), and also in Baltimore (Miller;; but in 
these cities the greatest mortality is in July, which is their hottest month, 
while in this country August is usually the hottest month, and the month when 
diarrhoea is most prevalent. The above table bears out the general state- 
ment that diarrhoea begins to be prevalent whenever the average tempera- 
ture of the twenty-four hours reaches 6o° F., and whenever this average 
temperature is exceeded by only a few degrees, diarrhoea prevails in a wide- 
spread epidemic. 

A similar table showing the corresponding number of cases of bronchial 
catarrh and bronchitis would show that these diseases were more prevalent 
and fatal during the cold and damp months of the year than in the warm 
and dry months ; and it has been argued that, just as bronchitis is produced 
by exposure to cold and damp, so diarrhoea is caused by a high temperature, 
giving rise to an intestinal catarrh or to a ' heat stroke.' But there are facts 
to show that the explanation is not so simple as this. It is certain that 
a single exposure to a high atmospheric temperature does not give rise to an 
intestinal catarrh ; that hot weather does not at once increase the number 
of cases of diarrhoea, but it is only after a high temperature has continued for 
some days ; and that infants at the breast, especially those under three 
months, though exposed to the same conditions of temperature, are only 
exceptionally attacked. 

Summer diarrhoea is much more prevalent and fatal in large cities than 
in country districts, and among the poorest classes who live in back-to-back 
houses in crowded courts and low- lying districts, while it is much less common 
among the better-housed classes of society, especially among those who live 
in the country or suburbs and upon a high and bracing site. 

It is most prevalent between the ages of three months and two years. 
The infants who suffer most are the weakly and dyspeptic ones, who are 
perhaps already suffering from an intestinal catarrh, and who are badly fed 
and improperly cared for — such, for instance, as the illegitimate class of 
infants who are put out to nurse. The infants who suffer least are the 
breast-fed infants ; thus out of nearly 2,000 fatal cases recorded by Emmet 
Holt, only some 3 per cent, had been breast-fed. This immunity is no doubt 
due to the fact that the milk they take is ' sterile,' and not swarming with 
organisms as cow's milk is apt to be. 

The epidemic prevalence of summer diarrhoea has been attributed, with 
more or less plausibility, to the ingestion of sour milk, unripe fruit, inhalation 
of sewer gas, emanations from the soil ; and possibly each of these may 
contribute to the cases of diarrhoea. That they arc not the constant and 
invariable cause is certain, as infants fed on sour milk by no means invariably 
suffer from diarrhoea, and the epidemic is too widespread to be explained on 
the unripe fruit theory ; and, moreover, diarrhoea is not especially prevalent 
in some towns where sewer gas is constantly present in the houses (Ballard). 
While it is certain that the ordinary lactic acid changes occurring in milk 
when it turns sour arc not the cause of diarrhoea, yet there is a strong 
probability that milk often is the vehicle by means of which certain micro- 
organisms or poisons enter the system, and give rise to the symptoms which 
are present in diarrhoea. 



88 Diseases of the Digestive System 

Fliigge has recently shown that some of the aerobic bacteria which are 
often present in milk, being derived from cow fasces, hayseeds, street dust, act 
on the casein and form peptones and ptomaines without turning the milk 
sour. Milk peptonised by these bacteria produces diarrhoea, and even death 
in mice and guinea pigs. A high temperature favours the development of 
these bacteria. 

That the diarrhoeal diseases are epidemic in hot weather is certain. Are 
any of the forms also infectious? In some recorded cases it certainly appears 
this has been so. Dr. Bruce Low x gives an account of four different out- 
breaks of diarrhoea in which it appears that the disease was communicated 
by contagion. 

Among the conclusions which various observers have arrived at with 
reference to the etiology of summer diarrhoea, we may mention the following. 

Ballard believes the cause to be a micro-organism not yet detected or 
isolated which is constantly present in the superficial layers of the earth, 
which, entering the food, develops under favourable conditions — either inside 
or outside the body — a virulent poison or ptomaine, which gives rise to the 
symptoms observed in the disease. This unknown micro-organism is sup- 
posed to play the same part in producing the disease as the comma bacillus 
does in Asiatic cholera. 

A. Baginsky, after an exhaustive experimental inquiry into the micro- 
organisms found in the stools of infants suffering from diarrhoea, failed to 
find any specific or pathogenic organism, but found many saprophytic or 
non-pathogenic bacteria, and he inclines to the belief that the decomposition 
products formed by these various forms of micro-organisms are the toxic 
substances which give rise to the disease. 

Meinert, while acknowledging that micro-organisms and their decom- 
position products when present in milk may give rise to an intestinal catarrh, 
believes that the acuter forms of summer diarrhoea are produced directly by 
the action of a high temperature, and are in reality a sort of heat stroke, 
having nothing to do with micro-organisms or ptomaine poisoning. 

In spite of all the facts before us, we are bound to acknowledge that we 
have no certain knowledge as to how a high temperature favours the occur- 
rence of diarrhoea. Although the fact that no pathogenic organism has been 
detected does not disprove its existence, we are not yet in a position to 
accept the conclusion that summer diarrhoea is a definite zymotic disease 
like Asiatic cholera or scarlet fever. A high atmospheric temperature, main- 
tained for days and nights together, favours the development of all sorts of 
saprophytic organisms, which can grow in every kind of food, both animal 
and vegetable, especially in milk, and, under certain conditions, produce 
poisons such as muscarine, which, when taken into the stomach, give rise to 
an irritant poisoning, with fever depression and collapse. It is certain that 
these organisms can flourish both inside and outside the body, and there is 
much reason for believing that they play an important part in giving rise to 
the severer forms of diarrhoea prevalent in the summer. 

Symptoms. — The symptoms may supervene suddenly in an infant in 
apparent health, though more frequently an infant is attacked who has 

1 Supplement to the Seventeenth Annual Report of the Local Government Board, 
1881-1888. 



Zymotic Diarrhoea 89 

already suffered for a day or two from intestinal disturbance or has had an 
attack of diarrhoea a week or two before. The first symptom is generally 
vomiting ; this is followed by a loose motion and accompanied by more or 
less fever, at the same time the infant is restless and irritable, the abdomen 
is distended with gas, and the legs are drawn up. The vomiting in the 
severest cases is very distressing, everything taken being rejected imme- 
diately, the vomited matters consisting of undigested food, and subsequently 
of simple mucus tinged with bile ; the stools are watery and consist of undi- 
gested food ; they are usually at first yellow and frothy, or green, containing 
lumps or flocculi of curd. Later, in severe cases, they consist of little else 
than slightly coloured water, or resemble the rice stools of cholera, and 
as the attack becomes more chronic they are of a dirty brown colour and 
very offensive. The tongue becomes coated with a thick white fur, 
the thirst is mostly extreme, the child eagerly taking the bottle or spoon, 
but vomiting immediately afterwards ; there is great restlessness, the child 
may doze for a short time, but rarely manages to get off into a sound sleep. 

The fever is seldom high and mostly intermittent, varying from 99 F. to 
102 F., in exceptional cases 105 F. or still higher. The stools become more 
and more frequent as the disease advances, sometimes being passed every few 
minutes, perhaps escaping unconsciously or being preceded by a short cry or 
an expression of pain on the infant's face. Very often more or less erythema 
or excoriation occurs about the anus and genitals. After a longer or shorter 
period, according to the acuteness of the case, symptoms of collapse make 
their appearance. There is a change in the infant's face which strikes the 
most casual observer ; the eyes are sunk in the head and kept partly closed, 
the fontanelle is depressed, the face is pallid or of an earthy tinge, the muscles 
of the neck and limbs lose their tonus, and the head rolls about when the 
infant is moved. There is no longer any great restlessness, the infant is 
generally listless and drowsy, and takes little or no notice of its friends. In 
this stage the vomiting usually ceases, the stools become less frequent and 
are smaller, and the abdomen becomes sunken and its walls flabby. 

The further progress of the attack depends upon whether improvement 
sets in ; if so, the diarrhoea ceases, more or less colour returns to the infant's 
face, it takes notice of its friends, and, though still weak, begins to use its 
limbs and take its food. In other cases it becomes more exhausted, it wastes 
rapidly, parasitic stomatitis makes its appearance, and frequently convul- 
sions occur, which quickly bring the end. The fatal event is often preceded 
by the occurrence of cerebral symptoms, such as coma and Cheyne-Stokcs 
respiration, a condition which has been termed 'false hydrocephalus" from 
its resemblance to meningitis, and indeed it is often believed by the friends 
and others that death has occurred through 'water on the brain.' In 
this state the coma is profound, the pupils dilated, and at times unequal, 
the respirations irregular, the child is pulseless, and there may be tvvitchings 
of the face or limbs. The state o\' the fontanelle will generally assist the 
diagnosis in deciding whether the cerebral symptoms are due to arterial 
anaemia of the brain, as in false hydrocephalus, or to meningitis : in the 
former case the fontanelle is depressed below the level o( the cranial bones, 
inasmuch as the brain occupies less space thin normally, in consequence 
of the arterial system being nearly empty, the result of a failing heart. 



90 Diseases of the Digestive System 

The length of time the disease lasts differs considerably. So rapidly fatal 
are some attacks that the term cholera infantum has been applied to therm 
and indeed in a few instances this resemblance to Asiatic cholera is very 
close indeed. Such cases occur much more commonly in the large cities of 
the continents of Europe and America than in our own cooler climate. 

The following case may be taken as an instance : 

A boy of five years of age was taken suddenly ill with vomiting and purging at i A.M. 
and died at 2.45 p. M. on the same day. When admitted to hospital at 11 A.M. he was 
completely collapsed ; the pupils contracted, the conjunctivas nearly insensible, the lips 
were pallid, the pulse could hardly be counted, the temperature was 104° F. In spite of 
brandy, ammonia, and nitrite of amyl, he failed to rally. The post-mortem examination 
showed the body to be well nourished and rigor mortis strongly marked. The intestines 
were distended with gas, and contained a small quantity of pale gelatinous fluid, the 
raucous membrane of the whole length of the alimentary canal was pink with minute ex- 
travasations of blood, and the solitary glands were enlarged. The tissues generally were 
pale and dry. The case occurred in August 1880, a summer which was unusually hot, 
and during which zymotic diarrhoea was very prevalent. 

In a few cases, convulsions may supervene during the first few days, and 
bring about a fatal termination. In the majority of fatal cases the duration 
is somewhat longer, perhaps a week to ten days, the infant passes through 
the acute attack, the symptoms then assume more or less of a dysenteric 
character, and it succumbs through exhaustion and inanition from a failure 
of the alimentary canal to recover its normal functions. Many infants who- 
escape with life in August, die in September or October from gastro- 
intestinal atrophy, which has followed as the result of the acute attack. 

Complications. — By far the most common complication of acute intes- 
tinal catarrh is broncho-pneumonia, or bronchitis and collapse of lung. The 
symptoms are apt to be latent, but any dyspncea or high temperature would 
necessarily call for a careful examination of the lungs. Thrombosis of the 
cerebral sinuses occasionally takes place in the later stages, but it is com- 
paratively rare ; the symptoms consist in distension of the veins emptying 
into the - cavernous sinus with oedema of the forehead and eyelids; there 
will also be tonic spasm of the limbs and neck, and convulsions. Albu- 
minuria frequently occurs during acute diarrhoea ; nephritis and uraemic 
convulsions have been described by some authors ; but we doubt if the con- 
vulsions which frequently occur towards the last are uraemic. Peritonitis 
occasionally occurs, hyperpyrexia may also occur. 

Sequelce. — Should the infant recover from the acute attack, it is by no- 
means certain that complete recovery will take place ; for it is extremely 
probable that gastro-intestinal atrophy may supervene, or a chronic diarrhoea 
remain, the result of chronic catarrh with follicular ulceration of the colon, 
sigmoid flexure, and rectum. In the latter case the symptoms are those of 
dysenteric diarrhoea ; defalcation is frequently accompanied by much pain 
and straining, the stools consist of mucus, often tinged with blood, or are dark 
brown and liquid. The rectum becomes prolapsed, and is sometimes returned 
with difficulty, and the child rapidly wastes. Not infrequently we see children,, 
usually under two years of age, who have gone through a severe attack of 
diarrhoea, extremely anaemic, and whose subcutaneous tissues, including the 
face, are cedematous. In such cases a trace of albumen may be found in the 



Cholera Infantum 91 

urine, but it is usually free from albumen. They have been described by some 
authors as suffering from nephritis. Our own experience is that the kidneys in 
such cases show very little pathological change, and moreover urine is freely 
secreted during life. This sequela, whatever may be the pathology of it, is, we 
are inclined to believe, the result of ptomaine poisoning. 

Diagnosis. — The principal difficulty in diagnosis occurs in the acute form 
of the disease, as it may be confounded with acute scarlet fever, sunstroke, 
or irritant poisoning, such as from eating poisonous fungi. We have several 
times been requested by a coroner to make a post-mortem on a child who 
has been seized with vomiting, purging, and high fever, with great depres- 
sion, followed by death in a few hours ; and we have been unable to say 
for certain, from the post-mortem appearance, whether the death has been 
due to malignant scarlet fever or acute inflammatory diarrhoea. The pro- 
blem has been solved in some instances by the occurrence of scarlet fever 
in the same house shortly afterwards. In the majority of cases the appear- 
ances seen in the throat would suffice for diagnosis. The diagnosis between 
sunstroke and acute cases of cholera infantum may be diffici It, as there may- 
be a high temperature in both ; but in most instances the gastro-intestinal 
disturbance is much more marked in the latter than the former. It must be 
borne in mind that some consider cholera infantum to be really cases of 
' heat stroke.' 

Prognosis. — Acute intestinal catarrh must always rank as a serious, 
disease, not only from its tendency to prove fatal during the attack itself, but 
because it so frequently passes on into a subacute or chronic form of catarrh 
to be succeeded by atrophy. The younger the infant, the more serious the 
prognosis becomes, especially if it has been artificially fed ; in older children,, 
though the attack may be severe and the depression produced very great, 
the disease usually terminates favourably. The onset of cerebral symptoms 
is of very unfavourable augury, and the chances are against the infant. 
though the case is not hopeless. Convulsions are generally followed by death. 
In those cases in which infants lapse into the chronic stage the prognosis is 
serious, as they are already exhausted by the acute attack. 

Morbid Anatomy. — If death has taken place early in the disease, the 
body is well nourished and perhaps even plump, but the face retains 
the same expression it had during life, the eyes and cheeks being sunken. 
On opening the body, minute haemorrhages are usually present on the sur- 
face of the lungs and heart, and there is hypostatic congestion at the bases 
of the lungs. The mucous membrane of the stomach and bowels is swollen 
and pink from capillary congestion, the congestion often being present in 
patches, and minute haemorrhages may have taken place. The mucous 
membrane of the large intestine is congested, especially along the summit oi 
the folds of the membrane. An excess of mucus is generally present, and 
the contents are liquid. The Peyer's patches and solitary glands arc most 
frequently swollen ; the kidneys are pale, the cortex frequently enlarged. 
In the later stages, the body is more or less emaciated, the lungs arc semi- 
solid at their bases from the presence of catarrhal pneumonia, the mucous 
membrane of the small intestine is swollen and congested, but the principal 
changes will be noted in the large intestines. Here the mucous membrane 
is generally much congested, especially about the cavum and descending 



'92 Diseases of the Digestive System 

■colon, there may be superficial ulceration or excoriation at the summits of 
the folds of mucous membrane, or the bowel may be pitted with deep but 
small ulcers from the results of breaking down and discharge of the solitary 
glands. Microscopical examination of the intestines shows a distension of 
the network of capillaries of the villi and mucous membrane, and an exuda- 
tion of leucocytes is mostly present in the sub-mucosa and between the 
tubules or crypts of Lieberkuhn. Numerous micro-organisms are present. 
The solitary glands especially in the large bowel are very often in a state 
•of softening in their centres, or their contents have discharged, giving rise to 
sharply cut ulcers. 

On examining the brain, no constant or indeed definite lesion is found ; 
in most cases the sinuses are distended with blood or occupied by a firm pale 
clot, but this condition of engorgement appears to be the result of death 
taking place through cessation of respiration, or during a convulsion, and is 
due to mechanical causes from interference with the return of blood to the 
lungs. The symptoms referable to the brain during the last few hours of 
life, coma, Cheyne-Stokes respiration, &c, have been attributed to exhaustion, 
.and an anaemic (arterial) condition of brain due to diminished arterial tension. 
The suggestion that they are due to uraemia is improbable, though it is not 
unlikely they are due to the absorption of ptomaines from the alimentary 
canal.- Meningitis is extremely rare ; in one case, however, which came 
under our notice, lymph was found about the optic commissures. 

Treatme?it. — The most important part of prophylactic treatment is con- 
nected with the food which the infant takes and the purity of the air which 
it breathes. No weakly infant who is being reared on artificial food and who 
has previously suffered from intestinal catarrh ought, if it is possible to avoid 
it, to remain in the crowded part of a large town during the hot weather, but 
should be sent away to a bracing seaside place, or country quarters should 
be selected among breezy hills. The greatest care should be exercised in 
the selection of pure milk and in its storage before it is taken by the 
patient, as there is little doubt that milk readily absorbs noxious gases, is 
•easily contaminated by micro-organisms present in the atmosphere, and 
changes are set up which render it unfit for food. All milk taken by infants 
and children during the summer months should be carefully sterilised in one 
of the milk sterilisers sold for the purpose. Care must also be taken that 
the infant is not given food in excess of its digestive powers, as undigested 
-curd or other foods are exceedingly likely to decompose in the alimentary 
canal and give rise to irritation and diarrhoea. The stools, both of infants 
at the breast and bottle-fed children, should be carefully watched, and any 
traces of undigested food or of unusual foulness or looseness of bowels 
should be the signal for lessening the amount of food taken. No infant at 
the breast should be weaned during the continuance of the hot weather, 
and if diarrhoea makes its appearance it should, if possible, be returned to 
the breast. 

The indications for treatment when the diarrhoea has commenced are in 
the first place to give a laxative to clear away all irritating or decomposing 
foods and relieve the congested bowel, and secondly to give food only in 
small quantities and of the blandest character. The first indication can be 
fulfilled by giving castor oil, as long ago advocated by Dr. Geo. Johnson, or 



Cholera Infantum 93 

by a dose or two of calomel. The former may be given in emulsion in com- 
bination with an unirritating antiseptic, asboracic acid or salicylate of soda ; 
the latter helps to prevent decomposition in the emulsion, and perhaps also 
plays a similar part in the stomach in checking putrefactive changes. (F. 12.) 

The oil may be given by itself in half-teaspoonful or teaspoonful doses, 
but it is apt to cause sickness. Instead of the castor oil, especially if there 
is much sickness, small doses of calomel maybe given, and on account of its 
small bulk and tasteless character it is in many respects to be preferred. It 
is better, if the attack is a sharp one, to give it in small and repeated doses,, 
especially in weakly infants ; \ to \ grain may be given to infants and 
young children every two hours, until one or two grains have been given. 
In the course of twelve hours or more, according to the intensity of the 
diarrhoea, all appearances of undigested food will have disappeared from the 
stools, the latter perhaps continuing frequent and watery. Stomach washing 
and irrigation of the large bowel have been largely practised both on the 
Continent and in America, and have the great advantage of removing at once 
the contents of the stomach and large bowel, but no irrigation can reach the 
small intestines. 

Unless the infant be at the breast, all milk or milk foods should be 
stopped, and barley water with white of egg substituted (p. 82). The most 
troublesome symptom at first is frequently the vomiting ; this may be 
constant, following every attempt at feeding, and it will be necessary to desist 
from all attempts at feeding for some hours, only moistening the mouth with 
a small brush dipped in iced water. Counter-irritation and hot applications 
to the abdomen at this stage are undoubtedly serviceable. For this purpose 
a liniment composed of five drops of oil of mustard to an ounce of cam- 
phorated oil may be gently rubbed over the abdomen, and spongio-piline 
or several folds of flannel wrung out of hot water applied. Or the spongio- 
piline may be wrung out of water at no° in which mustard has been diffused 
in the proportion of two tablespoonfuls to a gallon. 

The medicinal treatment of acute diarrhoea is often very unsatisfactory. 
The vomiting may continue, the stools in spite of the most careful dieting 
may be loose and frequent, and the child may rapidly lose ground. The drug 
which one is tempted to fly to is opium in one form or another, in the hopes of 
allaying irritation and diminishing the frequent flux from the bowels, which 
appear to the friends at least to be the cause of the child's increasing weak- 
ness and distress. It must, however, be borne in mind that the disease is 
something more than a congested, irritable state of bowels, in which the 
contents are rapidly passed downwards into the colon and rectum, since the 
diarrhoea is rather the result of a form of irritant poisoning. There cannot 
be the least doubt that in many cases with the cessation of the diarrhoea the 
child becomes no better, but rapidly passes into a condition of collapse with 
cerebral symptoms, due in all probability to toxaemia ; or the temperature 
rises and pneumonia supervenes. It must, moreover, be admitted that the 
treatment of the worse cases of summer diarrhoea by drugs is often unsuc- 
cessful, and this is borne out by the number o\ drugs which have been 
employed. 

The drug which has appeared to us the most successful in the vomit- 
ing in the early stages is carbolic arid, the glycerine of carbolic acid being 



94 Diseases of the Digestive System 

given in drop doses every two hours or even oftener. Carbolic acid has a 
sedative action on the stomach, and helps also to check the decomposition 
-changes which go on. Other drugs of a similar class, namely salol, creosote, 
resorcin, naphthalin, have been given as antiseptic remedies in the hopes of 
checking the putrefactive changes in the bowel and preventing the formation 
•of toxic products. Salicylate of soda has also been used by A. Jacobi, of 
New York, and also Dr. Emmet Holt ; he gives it in doses of one to three 
grains every two hours according to age. Resorcin may be given in \ to 2 
grain doses dissolved in water every two hours. Both bismuth in the form 
of carbonate and oxide and zinc oxide (F. 7 and 8) are usually of undoubted 
service. Opium, in the early stages, is useless and harmful, more especially 
when there is undigested food in the stools and where the vomiting is per- 
sistent. In the latter stages, if the stools continue small and numerous, 
especially if they approach the dysenteric type — the large bowel being chiefly 
involved — opium is of much value in soothing the patient and diminishing 
irritability. It is best given by enema. The advantage of the former 
method is that it is more slowly absorbed and its topical effects are useful ; 
one or two enemata of laudanum during the twenty-four hours will mostly 
relieve the irritative diarrhoea, when accompanied by straining and colicky 
pains, without the necessity of omitting or altering the medicine given by 
the mouth. Two to five drops of laudanum may be given in warm decoc- 
tion of starch per rectum to an infant of six months to twelve months, the 
effects carefully watched, and repeated in the course of six to twelve hours 
if necessary; -^ of a grain of morphia may be given subcutaneously to a 
•child over three years of age. If there be much fever, tepid sponging, or in 
cases of greater severity sponging with ice-cold water, may be practised. 

Stimulants may be required from the first, but it is wise to reserve them 
for a later stage, especially as they are apt to give rise to sickness. Brandy, 
a sound port, or champagne, are the form of alcoholic stimulants most useful, 
and they are usually required to be given freely in the later stages if collapse 
is threatened. Ammonia, camphor, and musk are valuable remedies if 
symptoms of collapse have made their appearance. Camphor may be given 
in the form of spirits of camphor, three or four drops every second hour ; 
•or musk. (F. 13.) 

Camphor and musk are not agreeable medicines to take, and are apt to 
cause nausea. 

Even when convalescence is established great care must be exercised 
for many weeks in the management of the patient ; the child is certain to 
be left with impaired digestive powers, anaemic, and liable to gastric or 
intestinal disturbance. A severe attack will often affect the child's health 
and development for many months, so that it is late in talking or standing 
alone, and at 18 months or two years of age resembles a child of 12 months 
old or less. Moreover, the diarrhoea may become chronic or return in a 
subacute form, and a child may thus be lost who has managed to struggle 
through the primary attack. The diet during convalescence requires the 
most extreme care, and a return to milk diet should not be allowed until 
there is evidence of much-improved digestive powers. Broths and beef tea 
made with barley or some light starchy food, meat juice, scraped underdone 
chops, whey, and Mellin's Food, may be given in moderation. 



Acute G astro-enteritis . 95 

The mineral acids, pepsine wine, decoction of pomegranate bark, the 
vegetable bitters and astringents, will be useful as the child improves. 

Summary. — Place the child in the coolest room of the house, and sponge 
frequently if there is much fever. 

Stop all forms of milk food, giving barley or arrowroot water with white 
•of egg, and veal broth ; if there is much vomiting stop all food for some 
hours. 

Apply hot fomentations or counter- irritation to the abdomen. 

Give castor oil or calomel till all undigested food has disappeared from 
the stools, followed by salol, zinc, bismuth, or carbolic acid. Later, if there 
is much restlessness or colic, give opium by the rectum. In severe cases 
brandy or other stimulant will be required, but it is apt to cause vomiting. 

In infants at the breast lessen the quantity of milk taken and give some 
barley water. 

Acute Castro-enteritis. Ptomaine Poisoning 

Under this head we refer to the gastro-intestinal disturbance which 
follows the ingestion of some food which contains a virulent animal poison. 
The commonest form of food which contains such poisons is milk, but so 
may tinned meat, sausages, mushrooms or mussels. Ptomaine poisoning is 
characterised by vomiting, colic, diarrhoea, fever, and the more severe cases 
by collapse. In an epidemic 1 which we had the opportunity of observing, 
upwards of 160 individuals were attacked, within a few hours of one another. 
Both adults and children Mere affected, in some families as many as twelve 
were attacked. It was proved that all those who suffered had taken milk 
from the same farm. On investigation Dr. Niven found that the milk from 
a cow suffering from ' Gargles,' or inflammation of the udder, had evidently 
been the cause of the epidemic. Some of those affected had only had a 
small amount of milk in their tea. We have seen similar attacks following 
the ingestion of tinned meat by children. It is not certain what form of 
micro-organism is the originator of the toxines in these cases, and it is un- 
certain whether the toxines are formed inside or outside the body. Gaertner 
has described a bacillus which he has called B. enteritis, and found in some 
•cases of sausage poisoning. 

Within a few hours of the inception of the poison there is vomiting, which 
is usually continued, and severe diarrhoea. The colic is very severe sometimes, 
giving rise to faintness. The temperature may rise to 105 F., or in mild 
cases it may hardly rise above normal. Convalescence is mostly protracted. 
The diagnosis is aided by the fact that several members of the same family 
are attacked, and in those cases where the milk supply is at fault several 
families will suffer who have the same milk. Occasionally influenza takes 
an epidemic form, and the diagnosis at first may not be easy. But the fact 
that several members of a family are seized within a few hours of one another, 
and then no other eases occur, should always raise the suspicion of ptomaine 
poisoning. The treatment will necessarily be to aid the s\stem in getting 
rid of the poison as quickly as possible, and then to relieve the excessive 
colic with sedatives. 

1 'An Occurrence of Milk Infection,' b\ Dr. J. Niven, Lancet, Jan. 1. . 1 



g6 Diseases of the Digestive System 

Acute Ileo-colitis. Dysenteric Diarrhoea 

Diarrhoea of a dysenteric character is sometimes secondary to acute 
catarrhal diarrhoea, or it may follow measles, whooping cough, or other 
zymotic disease. In these cases it is mostly chronic or at the most subacute. 
There is straining at stool : the evacuations contain much mucus and are 
streaked with blood. Prolapse of the rectum is common. In some cases, 
which occur almost entirely in older children, ileo-colitis is an exceedingly 
acute and fatal disease. Cases of this description have been recorded by 
Henoch, Goodhart, and Eustace Smith. The onset is sudden, with vomiting, 
colic, and fever, the latter usually not high ; there is much straining at stool, 
followed by the passage first of faecal matters, later blood and mucus only. 
There is mostly some abdominal tenderness, and in some instances a purpuric 
or petechial rash on the skin. There is certain to be great depression and 
rapidly increasing" weakness. There is often delirium at night. At the 
autopsy the last foot or so of the ileum is found to be involved, and the 
changes are more marked in the colon, but most of all in the sigmoid flexure 
and rectum. The mucous membrane is swollen and intensely injected with 
patches of thin membranous exudation, or if the child has lived some days 
there is ulceration of a superficial character. The etiology of these cases is 
obscure. They occur in the hot weather of summer, but their occurrence is 
not limited to this time. One of our cases occurred in April, at the height 
of an epidemic of influenza. (See below.) 

In one case coming under our notice in a girl of twelve years, who was 
admitted to hospital under the care of our colleague, Dr. Hutton, the attack 
commenced with vomiting and diarrhoea, followed by delirium, petechias on 
the skin, and bleeding from the nose. She was admitted to hospital on the 
sixth day of her illness in a collapsed condition, with a pulse of 190 and a 
temperature of 102 F. ; she passed loose stools containing some hard lumps 
with blood and mucus ; later, the epistaxis again supervened, the tempera- 
ture rose to 104 F., and she died exhausted on the ninth day of her illness. 
The post-mortem showed the folds of the mucous membrane of the colon to 
be of an ashy-grey colour with well-defined ulcers varying in size from a pin's 
head to half an inch in diameter : all the changes were more marked below 
the sigmoid flexure. 

In another case of a somewhat similar nature coming under our care, 
the symptoms so closely resembled those of an invagination of the intestines, 
that an exploratory incision was made into the abdominal cavity. Cases of 
intussusception are not infrequently diagnosed as ' dysentery,' but it is rare 
for the opposite mistake to be made. The case was shortly as follows : 

Acute ileo-colitis — Death. — A boy of nine years of age was suddenly seized (April 22, 
1 891) with pain in the abdomen whilst at school, followed by the passage of blood and 
mucus by the bowel ; he continued in this way during the' succeeding night. He was 
admitted to hospital next day, and, in spite of fomentations and opium, he passed twelve 
stools, consisting almost entirely of blood and mucus. Temperature 99-100° F. April ■ 
24. — The tenesmus and bloody stools continued, in spite of large enemata of warm 
water ; the latter brought away a small quantity of faecal matters. No tumour could be 
felt ; the abdomen was not distended nor tender to the touch. Temperature 97-99 '6 C F. 
In the evening, as no improvement had taken place, and the boy seemed rapidly sinking, 
it wa> decided to explore the abdominal cavity, in order to relieve an invagination of the 



Acute Ileo-colitis 97 

bowel if present. This was done ; but no invagination was found, only an intensely con- 
gested colon. Death followed about eight hours after. At the post-mortem the stomach 
and small intestines, to within twenty inches of the caecum, were found normal ; the last 
foot or two of ileum was found congested, with patches of thin membranous exudation. 
The mucous membrane of the colon, sigmoid flexure, and rectum was intensely injected, 
the changes in the lowest parts being most marked, the rectum being haemorrhagic. There 
were patches of thin membranous exudation, but no ulcers. 

These acute cases of dysenteric diarrhoea appear to occur in children of 
over eight or nine years rather than in younger children. 

Diagnosis. — Tenesmus, with passage of blood and mucus by the bowel, 
in an infant under a year old, should certainly suggest intussusception rather 
than ileo-colitis ; and a careful exploration of the rectum and palpation of 
the abdomen should certainly be made. In older children these symptoms 
indicate ileo-colitis rather than invagination ; fever, delirium, vomiting, also 
point the same way. 

Treatment. — In acute ileo-colitis only the blandest food should be given, 
such as arrowroot, veal broth, or white of egg mixture, and if there is vomit- 
ing, the less food given the better. Hot fomentations containing opium 
should be applied to the abdomen, and every effort made to allay the inflam- 
matory condition of the colon by small starch and opium enemata. Anything 
that can possibly irritate, such as purgatives or indigestible food, must 
be avoided, as likely to increase the peristalsis and tenesmus. Five to six 
ounces of warm starch mucilage and boracic acid with 10 minims of laudanum 
may be given to a child of ten years. Stimulants are certain to be required 
sooner or later. In mild or chronic cases irrigation of the bowel is often of 
the greatest service. Thin starchy mucilage may be used with bismuth 
oxide or nitrate, and the amount employed should be sufficiently large to 
reach the caecum. Laxatives, as rhubarb and soda or castor-oil emulsion, 
are also useful, 
avoided. 



Diseases of the Digestive System 



CHAPTER VI 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 
Chronic Gastro-intestinal Catarrh. Gastro-intestinal Atrophy 

In some cases a gastric catarrh exists with but little evidence of the intes- 
tines being in any way affected, and in other cases the intestines may be the 
only part of the alimentary canal which appears to suffer ; but in perhaps 
the majority of cases, especially in infants and small children, there is no 
sharply defined limitation between the two, the whole of the alimentary canal 
appearing to be involved. 

The terms chronic vomiting, chronic diarrhoea, simple atrophy, 
malnutrition, athrepsia, are sometimes applied, according to the most 
prominent symptom which is present ; thus, chronic vomiting is the most 
marked and striking symptom which may be present in catarrh of the 
stomach ; diarrhoea is mostly present, or at least more or less looseness of 
the bowels, in the early stages of an intestinal catarrh, though the latter may 
exist without any marked diarrhoea, or in the later stages there may be con- 
stipation. If the only marked symptoms are dyspepsia and wasting, then 
the term simple atrophy has been applied. In all these conditions, while 
the symptoms may differ, the anatomical groundwork is the same — namely, 
a chronic gastro-intestinal catarrh, which in later stages passes into a gastro- 
intestinal atrophy. 

Thus, an infant soon after birth, or perhaps when a few months old, 
suffers from repeated and frequent vomiting, or it suffers from diarrhoea, or 
if these are absent there are other chronic dyspeptic troubles, such as flatu- 
lence and colic ; it fails to thrive and gradually wastes, and after a more or 
less protracted illness, during which the wasting becomes extreme, it dies 
exhausted or is carried off by some intercurrent disease. In some cases the 
course is very short, perhaps only a few weeks, but in the majority the disease 
is chronic and the infant lives for months, suffering constantly from dys- 
pepsia, unable to digest its food, finally dwindling away and dying at last. 
The less severe cases, especially if they come under treatment, gradually 
improve, and after months of the most careful feeding and nursing completely 
recover, though such cases usually become rickety or are otherwise weakly. 
Recovery is only possible during the earlier stages ; if the catarrhal stage 
has passed on into one in which there is advanced atrophy of the mucous 
membrane of the stomach and intestines with the secreting glands, recovery 
is of course impossible. 



Chronic Intestinal Catarrh 99 

Experimental research has shown that there is a diminution in the amount 
of hydrochloric acid and pepsin secreted, while there is an excessive forma- 
tion of mucus, lactic, acetic, and butyric acids. Much gas is given off from 
the decomposing food. 

This gastro-intestinal atrophy rarely occurs in children over 18 months of 
age, and indeed is most common in infants under 6 months. Older children 
suffer from chronic intestinal catarrh, which rarely goes on to atrophy, though 
it is frequently the precursor of tuberculosis of the mesenteric glands. 

In the majority of cases, chronic gastro-intestinal catarrh is the result of 
improper feeding. Infants who come of a healthy stock and are nursed at 
the breast of healthy mothers rarely, if ever, suffer from it, at least as a 
primary disease. It is the infants who are fed from the first on cow's milk 
or the various forms of starchy foods that chiefly suffer. The infant may go 
on fairly well for the first few weeks or more, suffering more or less from 
dyspepsia ; then comes an attack of diarrhoea or vomiting, and forthwith it 
begins to go downhill ; no food seems to suit it, however often changed, and 
it never recovers its digestive powers, which appear to have been hopelessly 
damaged. Some infants appear to get on fairly well till they suffer from an 
attack of broncho-pneumonia, or measles, or whooping-cough, which they 
survive only to begin gradually to waste. In some few instances, more 
especially in dispensary practice, atrophic infants may be seen of a few 
months old, who have been, according to their mothers' accounts, entirely 
breast-fed. In these cases the infants have been congenitally weak or pre- 
mature, and very probably the mother's milk has been deficient in quality 
and quantity, or the child may have been fed whenever it cried, and in every 
way been badly cared for. 

Symptoms. — Infants. The history which is generally obtained from such 
cases is that they were suckled for a few weeks or months after birth, then 
the mother had to go to work or her milk failed, and the infant was made over 
to a friend or hireling to be artificially fed, and from this time it began to 
waste. On cross-questioning the mother or caretaker, it is found that it has 
been fed on sopped bread or biscuits, because cow's milk did not appear to 
satisfy it, or it vomited the milk curdled, and it has constantly suffered from 
colic, vomiting, or more commonly diarrhoea. On the other hand, there is 
sometimes constipation, but this usually has been preceded by diarrhoea ; 
the diarrhceal symptoms being most marked in those suffering during the 
summer months. If the symptoms be analysed, three stages in the course of 
the disease may be recognised as first clearly pointed out and emphasised by 
Parrot, whose description of these cases under the name of athrepsia leaves 
nothing to be desired. The early symptoms or first stage are those of a 
simple gastric or intestinal catarrh, in the second the progressive wasting be- 
comes the prominent phenomenon, and in the last stage the infant passes into 
an exhausted condition in which cerebral symptoms make their appearance. 
First stage. The infant suffers from a simple diarrhoea or looseness of the 
bowels ; the stools, instead of being bright yellow ami homogeneous, are liquid, 
curdy, and often green in colour, or contain an excess o\ mucus ; sometimes 
they consist almost entirely of stinking curd, or remains of milk ; the abdomen 
is distended with gas and remains constantly in this condition, the tongue is 
•coated, and patches of aphthous stomatitis appear in the mouth. The infant 

11 .: 



ioo Diseases of the Digestive System 

is restless, constantly whining, and will not sleep at night. Frequent vomit- 
ing may be a prominent symptom, the milk being returned curdled. The 
tissues become flabby, and then wasting commences. In the scco7id stage 
all the symptoms are intensified and the characteristic wasting becomes mani- 
fest. The stools for the most part are loose and frequent, and consist of un- 
digested food, being often pale and putty-like, with a peculiar odour ; at other 
times they are of a dark brown colour from the presence of altered bile. The 
infant is mostly voracious, liquid food does not appear to satisfy it, and by 
the mistaken kindness of its friends it is fed with sopped bread or some thick 
food, a diet which has the great merit in their eyes of keeping it quiet for a 
longer time than liquid food or diluted milk ; at times it cries incessantly, 
hardly ever appearing to sleep or only dozing for a short time unless under 
the influence of a ' soothing syrup ' supplied by its nurse. The mouth 
becomes the seat of parasitic stomatitis, the skin is harsh and dry, small boils 
or a lichenous rash make their appearance, the buttocks and genitals are raw 
and excoriated. Its temperature is below normal, the feet and hands are 
congested, the face has a pallid earthy tint, and a sickly lactic acid smell is 
given out from the body, especially the abdomen. The wasting is extreme, 
the face being shrivelled, the skin wrinkled and hanging in folds about the 
thighs and arms. In the third stage the infant passes into a moribund 
state ; it is too feeble to cry loudly, it becomes heavy and drowsy, taking 
little notice of anything. It becomes more and more somnolent, and death 
ensues, probably preceded by muscular twitchings, strabismus, or general 
convulsions. 

If we analyse the principal symptoms of the disease, we shall find that 
sometimes one symptom, as diarrhoea, sometimes another, as vomiting, is the 
most prominent. In the majority of the cases there is more or less diarrhcea 
throughout the whole course, so that such cases would come under the cate- 
gory of chronic diarrhoea, or this chronic condition may alternate with the 
acuter forms. The stools at first are yellow, liquid and frothy, with flocculi 
of semi-digested curd ; later they become green, the acid contents of the 
intestines acting on the bile pigments ; when the diarrhcea has become chronic 
the stools are either liquid and of a dirty brown colour, or more often, 
especially if milk is being taken, they are white and semi-liquid, the bile 
pigment having disappeared, and they consist of decomposing foul-smelling 
curd and mucus. Sometimes the stools consist almost entirely of mucus, 
the mucous membrane both of the small and large intestine secreting large 
quantities ; the child is constantly passing stools of mucus and undigested 
food. 

In some cases chronic vomiting is the most troublesome symptom, 
there being no diarrhoea but sometimes constipation. Cases of chronic 
vomiting with the consequent malnutrition are at times most difficult to deal 
with. So great is the irritability of the stomach that everything is rejected, 
either immediately after being taken, or after the lapse of perhaps half an 
hour. Diluted milk, peptonised preparations, meat juice, cream, and a variety 
of patent foods are tried one after another, separately or mixed ; each change 
only ends in disappointment, the infant becoming more and more wasted. 
Under such circumstances among the poorer classes the infant is given 
some thick food, as sopped bread or corn flour. Vomiting in many cases 



Chronic Intestinal Catarrh 101 

appears to be the result of the rapidity with which cow's milk is coagulated 
in the infant's stomach and of the hard lumps of curd which are thrown down, 
this occurring even where the milk is reduced to one part of milk to five of 
water. In other instances it appears to be due to the rapid changes occur- 
ring in the sugar of milk, lactic acid being formed ; the contents of the 
stomach are rejected, having a strong smell of sour and decomposing milk. 
In the catarrhal condition of the mucous membrane of the stomach much 
mucus is formed, while the gastric juice is weak, but its curdling power 
undiminished. Many such cases go from bad to worse, no food appearing 
to agree, all forms coming up alike. It must not be forgotten, in a case of 
constant vomiting, that it may be due to cerebral disease or some congenital 
defect. The prognosis in chronic vomiting is unfavourable if it commences 
in an artificially reared infant, and becomes thoroughly established, and is 
associated with progressive wasting. 

As the child wastes the skin becomes rough and harsh and hangs in folds 
upon the limbs and trunk, and very frequently, as the anaemia increases, the 
face, hands, and feet become cedematous. This oedema is due to anaemia 
rather than to any kidney complication. An erythematous rash is apt 
to make its appearance about the anus in those cases where there is 
much diarrhoea, and spread over the perineum and thighs. Small boils and 
abscesses are also common. Pemphigus may also appear. 

The temperature is constantly below normal, often measuring 96 or 
97 F. all through the twenty-four hours. 

Complicatioi2s. — Broncho-pneumonia is very common. Tuberculosis of 
the mesenteric or mediastinal glands may occur, or there may be a more 
general distribution of tubercle throughout the body. It must be borne in 
mind that it is only in the more severe and neglected cases that intestinal 
•catarrh passes on into atrophy ; in the majority of cases the course of the 
disease is intermittent, sometimes better, at other times worse, and as the 
child grows older the symptoms of rickets become grafted on to those of a 
chronic catarrh of the bowels. 

Older Children. — A chronic intestinal catarrh is not so serious a disease 
in children over two years of age as in infants, as it is rarely followed by an 
.atrophic condition of the glandular apparatus of the stomach and intestines, 
but takes rather the form of habitual indigestion than anything else. It is, 
however, apt to be exceedingly chronic in its course and to be followed by 
various evil consequences, the most serious of which is tuberculosis of the 
lymphatic glands, or there is a constant state of health below par, which in 
itself is a source of danger. Chronic catarrhal affections of mucous mem- 
branes, either of the nose, mouth, respiratory tract, or intestines, are ex- 
ceedingly apt to be followed by swelling and caseous degeneration of the 
lymphatic glands, with which the mucous membrane is connected. The 
intestinal lesion finds its origin for the most part in unsuitable food : the 
mucous membrane of the stomach and bowels is kept in a constant state of 
irritation by food r which is too great in quantity or of too indigestible 
character. Weakly children are especially apt to suffer, particularly those 
who are brought up in our large cities and whose time is spent cither indoors 
or playing in the street. Children who suffer habitualh from rhinitis, 
chronic tonsillitis, or chronic disease o\ the strumous type, are the chief 



102 Diseases of the Digestive System 

sufferers from chronic gastro-intestinal catarrh. It is very common in 
rickety children. Both the children of the well-to-do and of the poor classes 
suffer. 

Symptoms. — There is habitual indigestion with perverted appetite, the 
child refusing its bread and milk and craving for ' tasty' bits from its parents' 
table, or altogether refusing its meals unless its food is highly seasoned ; at 
other times the appetite is excessive. The abdomen is invariably rounded, 
from the constant distension of the stomach and intestines with gas given off 
from the decomposing half-digested food. This distension is very frequently 
accompanied by more or less pain. The face is generally pale with, 
dark areolae around the eyes, fat is absorbed as the disease progresses, the 
muscles become flabby, and the emaciation of the child contrasts markedly 
with its large tumid abdomen. Such children have usually coated tongues,, 
at other times the tongue is red and glazed, showing the enlarged fungiform 
papillae more distinctly than usual and resembling the ' strawberry tongue ' 
of scarlet fever. Sometimes the surface has a worm-eaten appearance,, 
being coated with a thick fur except in irregular sinuous patches where the 
surface is red and glazed. The bowels are generally confined, the stools being, 
frequently pasty with much mucus ; there are apt to be intercurrent attacks 
of vomiting and diarrhcea. There is very frequently more or less feverish- 
ness at night, especially in the subacute cases. Headaches are common,, 
there is often restlessness at night, grinding of teeth, and night terrors. Some- 
times when the disease is subacute, and there is some feverishness towards 
evening, the symptoms resemble mild typhoid fever and constitute what at 
one time was called ' infantile intermittent fever.' It is important to bear in 
mind that subacute intestinal catarrh may be present with an evening ex- 
acerbation of temperature as the principal symptom and with no vomiting 
or diarrhcea. An intermittent fever during early childhood with no pulmo- 
nary symptoms is probably, if typhoid can be excluded, due to an intestinal 
catarrh. It will not fail to be noticed that diarrhcea is a prominent symptom 
in the majority of cases of infants suffering from chronic intestinal catarrh 7 
while in older children not only is the diarrhcea not present, but there is 
usually constipation. The explanation of this is perhaps not very clear, but 
it must be borne in mind that those cases where diarrhcea is present and 
excessive are more acute in character and run a more rapid course than those 
where the bowels are less irritable ; there is also more likely to be diarrhcea in 
the early stages where the mucous membrane is congested, than in the later 
stages where the bowels have become more tolerant of irritation and the 
muscular walls wasted through long illness. 

In some cases of intestinal catarrh, especially in those which complicate 
or follow whooping cough, there is an excessive formation of mucus from the 
intestinal walls ; Dr. Eustace Smith has called special attention to these 
cases under the name of ■ mucous disease.' The bowels are usually loose, 
the stools consisting largely of mucus, or an aperient may bring away large 
quantities of mucus. In the worst cases, when^this form of disease complicates 
whooping cough, the prognosis is bad. 

Diagnosis. — The disease most likely to be confounded with chronic intes- 
tinal catarrh is tuberculosis of the mesenteric glands, or the early stages of 
tubercular meningitis. During the first three or four years of life, it happens 



Chronic Intestinal Catarrh 103 

very frequently that infants or young children are thought to have 'consump- 
tion of the bowels,' because they have capricious appetites, ' pot-bellies,' and 
have lost much flesh, when in reality they are suffering from a chronic intes- 
tinal catarrh. That the diagnosis is often difficult is only what is to be ex- 
pected when it is remembered that an intestinal catarrh of more or less severity 
is the exciting cause of mesenteric tuberculosis ; and in an advanced case, it 
may be quite impossible to say if a tuberculosis of the glands has supervened. 
Mesenteric disease is, however, much less common than simple intestinal 
catarrh, and is infinitely less so during the first six months of life than gastro- 
intestinal atrophy. Any evidence of tubercle in the lungs, or enlarged veins 
on the surface of the abdomen, or the detection of rounded masses by palpa- 
tion in the abdomen, would favour a diagnosis of mesenteric disease. In 
older children the fact that those suffering from intestinal catarrh grind the 
teeth, are restless at night, are subject to night terrors and headaches, is 
sufficient for most parents to become alarmed, fearing that the child is com- 
mencing with tubercular meningitis. 

Morbid Anatomy. — Chronic Gastro-i?ztestinal Catarrh. — In the early 
stages there is swelling, and injection of the mucous membrane of the 
stomach, and small and large intestine. The surface is grey, streaked with red, 
and there is an excess of mucus : the changes are usually most marked in the 
ileum and colon, especially about the sigmoid flexure ; in these places the 
solitary glands are enlarged, the mucous membrane is raised in folds, and 
often much injected, and follicular ulceration may be present. The micro- 
scopical appearances somewhat resemble those already described in acute 
catarrh. The surface of the mucous membrane of the stomach is covered 
with masses of leucocytes and micrococci embedded in mucus. The capil- 
laries are everywhere distended, the gastric glands are separated from one 
another by columns of leucocytes effused between them, the whole mucous 
membrane is swollen, and the muscular layer thickened. 

Similar changes are seen in the intestines, leucocytes are present in large 
numbers in the submucosa and between Lieberkuhn's glands, the latter are 
compressed and finally disappear, so that in places only masses of round cells 
are seen taking the place of the glands. A stage of atrophy succeeds that of 
chronic catarrh, and the appearances presented are those of a wasting of the 
mucous membrane, and a destruction of the secreting glands. The chronic 
swelling of the mucosa, and infiltration with leucocytes, have led to a wasting 
and cicatrisation of the tubular glands ; but death usually takes place before 
this stage is reached. 

In infantile atrophy the stomach and intestines are distended with gas, 
the former is frequently dilated, the mucous membrane is everywhere pale, 
the intestines are thin and translucent. This is especially marked in the 
more advanced cases, the intestinal walls are exceedingly thin, the solitary 
glands and Peyer's patches are wasted and have almost disappeared, with 
perhaps brownish spots or streaks where minute haemorrhages have taken 
place. These appearances will be varied with those of chronic catarrh 
according to the amount of atrophy that has taken place. The microscopical 
appearances show the mucous membrane of the stomach to have undergone 
wasting, being reduced to perhaps one-quarter its normal thickness. The 
gastric glands in places have completely disappeared, in other places they are 



104 Diseases of the Digestive System 

compressed and partly destroyed by round cells and young connective-tissue 
fibres. In the small intestines the appearances will be those of chronic 
catarrh, or these with the addition of destruction of the glandular apparatus. 
The tubular glands in places have disappeared, or are compressed or dilated 
by a connective-tissue growth, villi have completely disappeared, or only 
theirremains are present, thesolitary glands areatrophied or have disappeared. 
Similar changes may be found in the colon. Parrot has described various 
other lesions in the alimentary canal of infants dying within a few weeks of 
their birth ; such as a spread of the parasitic growth from the mouth to the 
stomach and intestine, usually the caecum. The same author has found 
minute circular ulcers in the stomach, from which haemorrhage has taken 
place, less often larger and irregularly shaped ones ; he has also seen the 
mucous membrane of the stomach to be the seat of a diphtheroid exudation. 
In the later stages, when the blood is profoundly altered, thrombosis of the 
renal veins, pulmonary veins, or sinuses of the brain may take place. Fatty 
degeneration {steatose of Parrot), softening, or meningeal haemorrhage, may 
take place in the brain. The kidney may be the seat of uric acid 
infarcts. 

Treatme?it. — The treatment of chronic gastro-intestinal catarrh in infants 
consists principally in careful feeding ; the blandest and least irritating 
forms of food must be selected, while frequent weighings of the infant should 
be resorted to in order to ascertain if any progress is being made. In 
infants under four months a wet nurse should be obtained if possible. 
Where there is much diarrhoea, milk must be used sparingly or altogether 
omitted for a while, as the hard curds formed in the stomach are beyond the 
digestive powers of the weakened stomach and intestines. Small quantities 
of whey and barley water, white of egg and barley water, or the juice of an 
underdone chop, may be given at short intervals during both day and night. 
Improvement having taken place as regards the diarrhoea, milk in some 
form or other must be given. Some of the forms of desiccated milk already 
referred to (p. 51) may be used alternately with raw beef juice and some 
malted food such as Mellin ; s, and the cream mixture referred to (p. 46) may 
also be tried. Peptonised milk is often of much value under these circum- 
stances, when made by mixing 3 oz. of boiling decoction of arrowroot with 3 oz. 
of cold milk, adding two teaspoonfuls of cream, half a peptonising powder 
(Benger), sweetening, and giving it to the infant after it has stood for fifteen 
minutes. Every care must be taken that the feeding bottle is clean, and 
the food prepared with the most scrupulous care. Whenever the weather 
permits, the infant must be taken into the open air as much as possible. 
The medicines given must be selected according to the most prominent 
symptoms. If the stools are loose, contain much mucus and curd, and are 
foul or stinking, small doses of castor-oil emulsion or calomel should be 
given, to be followed by bismuth and small doses of opium. If the stools 
are dark brown or yellow and very liquid, astringents in the form of extract 
of logwood, catechu, or pomegranate will be of most service, especially if 
small doses of opium are given by the bowel. If the diarrhoea approach the 
dysenteric type, much mucus and blood being passed with straining and 
forcing down, enemata of nitrate of silver and opium and alum or vegetable 
astringents will be useful. (F. 12, 13, 14.) 






Chronic Intestinal Catarrh 105 

The treatment of chronic gastric catarrh in infants when it has become 
-confirmed is very often extremely discouraging. 

In the milder forms of vomiting the importance of diluting the milk so 
as to reduce the quantity of curd, or of peptonising the milk to gain the same 
end, must be insisted upon. It is also of much importance not to give food 
too frequently, but to give the stomach a complete rest for several hours. 
In severer cases in which milk or whey, in whatever form it is given, returns 
sour and curdled in a few minutes, other food must be substituted at least 
for a time. In such cases Mellin's Food, either made with water or weak veal 
broth (half a pound to the pint), may be given ; the bottle being discontinued 
and the infant fed with a spoon. Instead of veal broth, raw meat juice or 
' liquid meat' may be used. After a few days, milk may be again tried, or 
small quantities of cream may be added to the Mellin's Food in lieu of the 
meat juice. In this acid condition of stomach small doses of sodii bicarb, 
and pepsine are often very useful. (F. 15.) 

In older children careful dieting is of the utmost importance, and the first 
•difficulty encountered will probably be that the child has been over-indulged 
and so spoilt by its parents that it is difficult to get it to take a carefully 
selected and restricted diet. In arranging a diet it must be borne in mind 
that the child should take only such quantities as the impaired state of 
the digestive juices can deal with, any excess being liable to undergo decom- 
position in the intestines, and give rise to flatulence and other troubles. It 
is also most important to give the stomach a complete rest during the intervals 
between meals ; sweet biscuits taken during the morning or a run on the 
kitchen at frequent intervals during the day are fruitful sources of chronic 
indigestion, and the plainest and most peremptory directions should be given 
to the parents by the medical attendant that nothing whatever should be 
taken except at regular meals. If the child refuses or only half gets through 
its breakfast, this should by no means be supplemented by a second edition 
at the parents' table, or a tasty lunch to make up for the morning's deficiencies. 
It is wiser by far, if the breakfast is but half taken, to let the child wait till the 
next meal ; a little starvation can do no harm, at any rate much less than 
over-indulgence and the formation of bad habits. The importance of fresh 
air and change of scene in cases of habitual indigestion can hardly be over- 
estimated. The worst form of exercise is a 'constitutional' taken with the 
nurse or governess ; outdoor games of various kinds, gymnastics, riding, or 
driving, or some form of recreation which will occupy the mind and give an 
interest to the exercise, are far preferable to any dull routine. A change to 
the seaside, or some bracing elevated inland site where there is a keen 
cool air, will often work wonders in these cases. It must, however, be re- 
membered that such cases are often worse, or there is no improvement, at 
first ; children when first removed to the seaside are apt to do too much and 
eat too much ; they are ovcr-tircd and fretful at night, and attacks of dyspepsia 
•or perhaps eczematous or other eruptions occur. A caution is often neces- 
sary to prevent this. 

It is wiser in most eases to lay down a complete diet chart for the gui- 
dance of the parents, though a certain latitude must necessarily be permitted 
on account of varying tastes. The following diet tables maybe taken as 
samples, which can be modified according to circumstances : 



106 Diseases of the Digestive System 

Diet for a child of 5 to 7 years, indigestion not severe : 

Breakfast, 8 A.M. — A breakfast cupful (8 oz.) of bread and milk, made 
from whole meal bread ; a teaspoonful of malt extract may be added ; this 
may be followed two or three times a week by the yolk of a lightly boiled egg 
on strips of toast, or a piece of toast and dripping or bacon fat. 

Dinner, 12 to i P.M. — A broiled mutton chop, finely minced, or fresh white 
fish, with mashed potato, spinach, or French beans ; to be followed by ground 
rice pudding or a baked apple. Milk to drink. 

Tea, 4 to 5 p.m. — A cup of cocoa and milk, with toast or stale bread. 

Supper, 7 P.M. — A cup of beef tea or mutton broth. 

In the more severe and protracted cases it is well to avoid farinaceous 
food as much as possible, as recommended by Dr. Eustace Smith. 

Breakfast, 8 a.m. — Half to three-quarters of a pint of fresh milk, alkali - 
nised by twenty drops of the saccharated solution of lime ; a slice of toast 
with yolk of egg, or fresh fish. 

Dinner, 12-1 P.M. — A small mutton chop or boiled sole, a thin slice of 
stale bread, with half to a wineglassful of sherry or bitter beer, well diluted. 

Tea, 4-5 p.m. — Same as breakfast. 

Supper, 7 p.m. — A cup of beef tea. 

In some of these cases of chronic dyspepsia, especially where the stools 
are pale, the amount of milk which the child takes must be lessened in 
quantity — the milk given being much diluted with cocoa, or peptonised 
milk may be given. 

In all cases of habitual indigestion it is of much importance to sponge 
every morning with cold or tepid water (6o°~yo°), keeping the child's feet in 
warm water during the process, if it is subject to cold feet or has a sluggish 
circulation. A shower bath is often of much service. After the morning's 
bath friction with as rough a towel as the child's skin can stand should be 
used. The child's dress should consist of woollen garments next to the skin., 
and every chance of getting cold should be avoided. 

The medicines which are of the greatest value in these cases are nitric 
acid in combination with helaline and pepsine (Xf\xv to Tl]xxx of the liq.), or 
euonymin and pepsine may be given. 

Arsenic is often of much value, but requires to be given in increasing 
doses to bring out its full value. For a child of seven years, three-drop doses 
may be given, and gradually increased to six drops, or it may be given in 
small granules, which are readily taken by children, preferably an hour after 
food. At the same time it is well to order a saline purgative, which shall 
keep the bowels relaxed rather than loose. 

Alkalies with senna or rhubarb are often prescribed with much advantage. 
(F. 16, 17, 18.) 

Later, when convalescence is established, acids and bitters should be 
given. 

If the bowels keep confined, a small granule containing half a grain or 
aqueous extract of aloes may be taken at dinner time daily ; in many cases a 
grain will be required to keep the bowels well open. This may be supple- 
mented, especially if the stools are pale, by an ounce or two of Hunjadi 
water, to which an equal quantity of warm water has been added, to be taken 
two or three times a week before breakfast, or Rubinat or Friederichshall 



Dilatation of Stomach 107 

water, half a wineglass to a wineglassful in warm water, or a teaspoonful of 
effervescing Carlsbad salts, may be taken before breakfast two or three- 
times a week, and decreased or increased according to the state of the 
bowels. 

Dilatation of Stomach. — Dilatation of the stomach during infancy is 
commonly the result of a long-continued gastric catarrh ; in rare cases it is 
secondary to a congenital stenosis of the pylorus or duodenum, or upper 
part of the small intestine. In the minority of cases the dilatation takes 
place rapidly, as in acute gastric or gastro-intestinal catarrh, or in ' cholera 
infantum/ but it is far more frequently found in weakly infants or children 
who have suffered for months from chronic dyspepsia and who are probably 
ansemic and rickety. It is easy to understand that, if the digestive fluids 
are weak and insufficient to properly digest the food, the curd of milk and 
starches decompose in the stomach, and gases are given off in large quanti- 
ties. The constant distension of the stomach keeps the muscular walls on 
the stretch, the muscular fibres become thin and atrophic, and the distended. 




Fig. 14. — Hour-glass constriction of stomach, from an infant of five months. (Natural size.) 

condition tends to become permanent. The muscular mucous membrane,, 
including the glandular elements, is wasted. The effect of a dilated 
stomach is to add to the dyspeptic troubles ; like a dilated and powerless 
bladder, its contents become stagnant and decompose ; it never thoroughly 
empties itself, but always contains much mucus and decomposing curd 
of milk. These dilated stomachs sometimes reach an enormous size. 
Henschel records a stomach of an infant two weeks old with a capacity of 
190 cc. (normal, 70 cc.) ; an infant of three months with a stomach of a 
capacity of 485 cc. (normal, 150 cc.) ; another of four months, of 500 cc 
(normal, 180 cc.) ; and another of ten months of 650 cc. (normal, 300 cc). 
The symptoms are not very definite, and we have on several occasions dis- 
covered -post mortem a considerably dilated stomach, which we had not 
detected during life. There is chronic dyspepsia, discomfort after food, 
distension of the stomach with gases, coated tongue, and in some cases 
chronic vomiting. The diagnosis may be difficult : in some eases the limits 
of the dilated stomach may be mapped out by percussion, but this can only 
be done if the colon and small intestines are not distended. If the colon is 



108 Diseases of the Digestive System 

much distended, it will probably be impossible to distinguish between the 
tympanitic note produced by percussing the stomach and that produced by 
percussing the colon. A splashing sound may sometimes be produced by 
shaking the child, in cases of dilated stomach, if there is much fluid in the 
stomach. The prognosis is not necessarily bad, as there can be little doubt 
that under favourable conditions the stomach may recover itself. The 
treatment is that of chronic dyspepsia : washing out is especially useful. 

In rare cases there is a congenital stenosis of the pylorus with a secondary 
dilatation and hypertrophy of the walls of the stomach. Two cases are 
recorded by Hirschsprung ; l one of these cases lived a month, the other six 
months ; the prominent symptoms were vomiting, constipation, and progres- 
sive wasting. At the post-mortem in each case the pylorus was thickened, 
the opening stenosed so as only to admit a medium-sized sound, and the 
stomach dilated and the walls hypertrophied. Henschel relates two some- 
what similar cases. 2 

Dilatation of the stomach, sometimes extreme in degree, is present in 
•congenital obstruction of the duodenum and ileum. (See p. 141.) 

Malformations of the Stomach. — These are certainly uncommon, but 
a slight degree of hour-glass constriction which had been unsuspected during 
life may at times be found at post-mortems. In a case of our own in 
-which we made the section, but did not see the infant during life, there was 
.a well-marked contraction in the central portion of the stomach. (See 
fig. 14.) There was a history of constant vomiting during life. 

Carcinoma of the Stomach. — New growths in the alimentary canal 
are exceedingly rare in early life. The best-known case is that recorded by 
Dr. Cullingworth. In this case a columnar epithelioma was found in the 
stomach of an infant of five weeks old. We have met with one case, 
but the new growth was more duodenal than gastric. The case was shortly 
as follows : 

Oliver G. , aged 8 years, was admitted to hospital Sept. 1, 1890. He was a thin boy, 
with distended abdomen and symptoms of cystitis. There had been no vomiting, pain, 
or diarrhoea. The abdominal distension was considerable : the coils of intestines could 
be distinctly seen through the abdominal walls. There was no tenderness, and no tumour 
could be felt. He was discharged February 21, 1891, somewhat improved, having made 
flesh during his stay. He was' re-admitted April 23, 1891. The abdomen was distended 
and tender, and a tumour could be felt below the edge of the liver, to the right of, and 
about the same level as, the umbilicus. There were frequent attacks of severe colicky 
pains. He gradually emaciated, and died May ^15. The post-mortem showed that the 
transverse colon near the hepatic flexure, the duodenum and omentum, were matted 
together ; the stomach was dilated, and its walls thickened. The pyloric opening just 
admitted the forefinger ; on the cardiac side of the pylorus were two small growths, the 
size of peas ; on the duodenal side there was an irregular cavity, the walls of the first part 
of the duodenum having been destroyed by a new growth ; lower down were some polypoid- 
looking growths ; below these the mucous membrane was normal. Microscopical exami- 
nation showed the growth to be a columnar epithelioma. 

TTlcer of stomach. — Tubercular ulcers of the stomach occur in children, 
tout we have never seen an example. When puberty is passed simple ulcers 
may occur. We have known severe haematemesis occur from ulcers in the 

jejunum. 

1 Jahrbuch fur Kinderkr. Band xxviii. Heft 1. 

2 Archiv f. Kinderh Band xiii. Heft 1. 



Intestinal Worms 



09- 



Intestinal Worms 

The worms which most commonly infest children are the thread worms,, 
round worms, and tape worms, of which the former are the most common. 

Thread Worms (Oxyuris). — These troublesome pests inhabit the lower 
bowel, namely caecum, colon, sigmoid flexure and rectum, and also the vagina, 
an unhealthy state of the mucous membrane with sluggish bowels appear- 
ing to favour their development. To the naked eye they appear like short 




Dictionary of Medicine.) 

pieces of white thread : under a low power the females, which are the most 
numerous, are seen to taper at each end, and their uterine ducts will be seen 
to contain numerous oval-shaped ova, some of the latter containing embryos. 
These parasites gain entrance into the system by the ova being taken in the 
food, or perhaps more frequently by means of the ova adhering to the fingers 
of those already affected ; they are thus conveyed directly or indirectly to 
others. The extreme fertility of these worms makes it certain that anyone 
who is affected with thread worms and is not of scrupulously cleanly habits 
will have ova adhering to the neighbourhood of the anus which may be 
transferred by the fingers to the individual's own mouth or to others. The 
symptoms are very uncertain, the diagnosis being usually made by the 
patient's friends detecting the parasites in the chamber vessel used by the 
child. The most common symptom to call attention to 
the presence of thread worms is the irritation and itching 
which they are apt to give rise to at the anus or entrance 
to the vagina. Girls will suffer from excessive discharge 
of mucus from the vagina, sometimes containing blood, 
from the presence of oxyurides in the vagina or the result 
of scratching. In many cases the presence of thread 
worms seems to give rise to no symptoms whatever 
Weakly anaemic children with sluggish bowels are most Fig. 16.— Eggs of Oxy- 
often affected. The treatment consists in expelling the KrS^b^Tx e -o 
worms, preventing their re-entrance, and in improving the diam. (Quam's ' 1 He- 
health of the child so that it is less likely to providea favour- tionary of Medidne - ) 
able cultivation ground for these unwelcome guests. The first indication is best 
fulfilled by a sharp purge to expel or else to drive them into the lower bowel, 
to be followed by enemata to destroy those present in the colon and rectum, 
and wash away any excess of mucus present ; a grain to two grains of calomel, 
in combination with two or three grains of resin of scammony, may be given to 
children of three to eight years of age overnight : and the following evening, 
if the bowels have been well acted upon, an enema of infusion of quassia as 
large as can be given should be used. It will be well to repeat the enemata 
every other evening for a week or two. Great care should be exercised to 
see that the child is washed about the genitals with soap and water after 
each stool to prevent re-infection. Injections should be used repeated!) to 




I io Diseases of the Digestive System 

free the vagina from any of these worms, if there is any vaginitis or irritation. 
Weak carbolic acid lotions will answer very well, and some dilute red oxide 
of mercury ointment 1-3 may be smeared at the entrance to the vagina. 
The general health of the child must also be thought of and a careful diet 
prescribed, excess of sweets and starches being avoided. If constipation 
exist. Rubinat or Hunjadi water should be given every other morning before 
breakfast, in sufficient quantity to produce a soft stool without purging : sul- 
phate of iron, gr. ^-j, with spirits of chloroform and orange flower water, 
twice a day, is often very useful. Cod liver oil in selected cases is of great 
service. 

Round Worms Ascaris lumbricoides . — The common round worm 
measures from four to twelve inches in length, the females being somewhat 
longer than the males ; they are reddish white and have more or less resem- 
blance to common earth worms. They mostly inhabit the small intestines, 
"but are apt to wander into the stomach, large intestines, or even into the 
gall bladder. Several may exist in the intestine at the same time, in ex- 
ceptional instances many hundreds may be present. They gain entrance 
into the system by means of their ova, which are swallowed with the food : 
the shells surrounding the ova are dissolved by the gastric juice, setting free 
the embryos. The symptoms produced by the presence of round worms 
cannot be certainly distinguished from those of dyspepsia or intestinal catarrh, 
with which the ascarides are so commonly associated. The passage of a 
round worm per rectum is often the first thing to call attention to the subject ; 
on the other hand, mothers often dogmatically assert that their child has 
worms because he ' picks his nose ; and his *' food appears to do him no good. 
The latter symptoms, it is needless to say. are not diagnostic of the presence 
of worms, but of an unhealthy state of the alimentary canal. The presence 
of one or two round worms rarely produces any symptom ^ter se, unless they 
pass into the stomach or bile duct. In larger numbers they may give rise to 
colicky pains, especially at night ; diarrhoea, vomiting, and symptoms of ob- 
struction of the bowels have occasionally resulted. In rare instances worms 
have found their way into the peritoneal cavity and been discharged with 
the contents of an abscess through the abdominal wall. The treatment is not 
as difficult as the diagnosis. Santonin combined with calomel or castor oil 
should be given, and is almost certainly successful after a dose or two has 
been given. Santonin, gr. j-iij. calomel, gr. §- j, may be given overnight, and 
some fluid magnesia or other saline next morning before breakfast. Or the 
santonin dissolved in two or three teaspoonfuls of castor oil may be given 
before breakfast. The santonin may be repeated once or twice, but not oftener, 
until the physiological effects (if any have been produced have passed off. If 
the santonin cause vomiting, smaller doses should be tried or compound 
scammony powder substituted. 

Tape Worms are as common in children as in adults, both the Tama 
solium and T. mediocanellata being found. Infants and young children less 
often act as hosts for tapeworms, but they have been found in infants under 
a year old. Attention is first called to the fact by the passage of the joints 
or proglottides in the stools. Cider children will often complain of pain in 
the epigastrium, and peculiar movements are felt inside ; they are apt also 
to lose flesh and suffer from various dyspeptic symptoms. The difficulty 



Ascites 1 1 r 

of dislodging the greater part of the creature is not great, but the head is not 
so easily expelled, especially that of the Tcenia solium. The success of the 
treatment by means of the administration of male fern depends upon the in- 
testine containing as little food as possible. A dose of castor oil should be 
given overnight sufficiently large to act freely before morning ; twenty to 
thirty drops of etherial extract of male fern (freshly prepared) should be given 
in half an ounce of mucilage and water before breakfast ; breakfast should 
consist of some light refreshment such as beef tea : at noon another dose of 
castor oil should be given, which will act in the course of the day, bringing 
away the intruder. Careful search should be made for the head, bearing in 
mind that the joints are likely to break about an inch from the head, that the 
latter is about the size of a large pin's head, and the thickness of the worm 
itself near the head is only that of a stout thread. 

If, after careful search by a competent observer, the head is not discovered 
in the stools, after a few days the treatment may be repeated, but it is not 
wise to continue to repeat the male fern, as toxic symptoms are apt to arise. 
Decoction of pomegranate root may be substituted if it is necessary to con- 
tinue the treatment. 

Ascites. — Fluid is sometimes present in the peritoneal cavity of the child 
without dropsy elsewhere, and it may be difficult to decide as to its cause. 
The diagnosis of ascites when it forms part of a general dropsy, as in cardiac 
disease or renal disease, is easy and does not call for special comment. 

An ascites which is primary in a child is usually the result of some lesion of 
the peritoneum, as chronic peritonitis, or the result of portal obstruction such 
as cirrhosis or perihepatitis. The detection of a large or moderate quantity 
of fluid in the peritoneal cavity is not difficult, the percussion note being- 
dull in the flanks, while the region round the umbilicus is tympanitic 
in consequence of the distended intestines floating upwards when the patient 
is lying on his back ; change of position on to the side will float the intes- 
tines to the highest point, and the flank which is uppermost will now be 
resonant. While change of the patient's position will thus cause the fluid 
to gravitate to the lowest point if it is free in the peritoneal cavity, it 
must be borne in mind that in chronic peritonitis there may be a matting 
together of the intestines which prevents them from floating upwards, and 
consequently there may be no alteration in the percussion note after change 
of position. The amount of dullness to percussion may vary from day to day 
according to the varying distension of the intestines. In ascites the super- 
ficial veins of the abdomen are usually enlarged, the skin becomes shiny 
and stretched if the fluid is excessive, and often the umbilicus is protruded 
and pouched out, containing fluid which can be pressed back into the 
abdominal cavity. The detection of a small quantity of fluid in the abdo- 
men is difficult, especially when the intestines are much distended with 
gas and the large bowel is loaded with faeces, the latter giving a more 
or less dull percussion note in the flanks. Fluctuation nun be fell 
by passing the finger into the rectum ; fluid may thus lie detected in 
the pelvis. A careful observer is hardly likely to mistake simple dis- 
tension of the intestines with gas for ascites ; the thrill imparted to the 
contained fluid by gently tapping the flank is absent in the flatulent dis- 
tension, and on percussion the abdomen is universally tympanitic fhe 



1 1 2 Diseases of the Digestive System 

diagnosis of the cause of the ascites is often difficult, as a large accumulation 
of fluid may be due to chronic peritonitis and closely resembles an ascites due 
to portal obstruction. Chronic peritonitis may be quite unaccompanied by 
pain or tenderness from first to last, and the fluid may be excessive. Any 
matting or induration of the omentum or intestines to be felt through the 
abdominal walls, or a slight evening rise in the temperature or signs of tuber- 
culosis elsewhere (as in the testis), or chronic diarrhoea, would be in favour 
of chronic peritoneal tuberculosis. A normal temperature, the ascitic fluid 
freely movable, the general health good, slight jaundice or bile pigment in 
the urine, would be in favour of portal obstruction, as cirrhosis or medias- 
tinitis. If the fluid is localised by the presence of adhesions, and does 
not occupy the whole peritoneal cavity, it is probably due to tuberculosis.. 
The possibility of hydatids of the peritoneum must be borne in mind. 



H3 



CHAPTER VII 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 

Acute Peritonitis 

ACUTE general peritonitis is not an uncommon disease during infancy and 
childhood. It occurs as a primary disease, and also spreading from some 
other part or originating in consequence of the leakage of the intestinal 
contents into the peritoneal cavity, or it may follow a blow or kick on 
the abdomen. The foetus also suffers from peritonitis perhaps more sub- 
acute than acute, and the adhesions which are left surrounding and matting 
the intestines are apt to interfere with the growth and development of the 
gut, and lead to stenosis or obstruction by narrowing the bowel or tying 
it up in coils. Acute peritonitis occurs in the newly born, secondary to " 
arteritis or septicaemia ; but such cases are rare in private practice. Apart 
from these cases, peritonitis is not common in infants and young children. 
Dr. West mentions a case of idiopathic peritonitis occurring in an infant of 
seven months, which proved fatal in six days ; the attack was sudden, ac- 
companied by vomiting and abdominal distension ; after death, lymph and 
serous fluid were found in the abdominal cavity. We have known it in 
infants and young children to spread from a suppurating mesenteric gland. 
Acute peritonitis occurs in older children by no means infrequently, super- 
vening, without known cause, in the midst of apparent health. Some- 
times cold or a more or less severe blow appears to be the starting point. 
At the ftost-inortem there is nothing to indicate where the inflammation 
commenced. Not infrequently the peritonitis is the result of some lesion in 
the caecum, vermiform appendix, or mesenteric glands. It sometimes occurs 
in tubercular subjects : thus a phthisical boy of nine years old was suddenly 
seized with pain in the abdomen and vomiting, and died in ten days : at the 
post-mortem an acute general peritonitis was present, and also adhesions 
from old peritonitis and some calcified mesenteric glands. Acute peritonitis 
may be caused by the spread of inflammation from other parts, as from the 
pleura, an empyema bursting through the diaphragm, from the pericardium r 
ulcers in the stomach, duodenum, ileum, or caecum, or from intussusception. 
It may occur in the course of typhoid fever from perforation ot the 
intestine and extravasation of faeces. It is rare in the course of scarlet 
fever, but it is not uncommon in the last stages of the succeeding nephritis, 
when uraemic phenomena have set in ; it is then mostly oi a purulent 
character. We have seen peritonitis post mortem, which appeared to have 
succeeded to or been associated with an acme intestinal catarrh, with 
symptoms of an inflammatory diarrhoea or an intestinal ulcer ; and it seems 

i 



1 14 Diseases of the Digestive System 

probable that, in some cases, the peritonitis maybe secondary to an intestinal 
lesion. 

Symptoms and Course. — The symptoms of acute peritonitis in the infant 
and child are by no means always as characteristic as they are in the adult, 
and cases will sometimes occur where extensive peritonitis is found at the 
post-mortem which was not suspected during life, especially when super- 
vening in the course of some other disease. 

The attack usually begins with vomiting, sometimes diarrhoea, and great 
pain and tenderness in the abdomen referred to the region of the umbilicus : 
the amount of tenderness on pressure varies even in cases where no opium 
has been given, and where the patient is under the influence of this drug pain 
may be entirely absent. Constipation after the onset is a marked feature 
when the attack is established, no faeces and often no wind passing by the 
bowel ; the vomiting is constant, the distension of the bowels very great, so 
that the coils of distended small intestines may be seen through the abdo- 
minal walls, and the case may readily be assumed to be obstruction of the 
bowels from some mechanical cause. Though no complete obstruction 
exists, yet the coils of intestine are seen post mortem to make sharp turns 
on one another, 'kinks' being formed, which, with the layers of lymph on 
their surface, must seriously impede the passage of their contents. The 
paralysis of the muscular coat of the bowel, by diminishing or arresting the 
normal peristaltic movements, further prevents the onward movement of the 
intestinal contents. The vomiting is mostly constant as long as food is 
given ; undigested food, bile, and sour-smelling intestinal contents may be 
brought up, but the vomited matters are never faecal as they are in hernia or 
intussusception. There is usually moderate fever, the temperature being 
101 to 102 F.,but a normal or subnormal temperature may persist through- 
out the case, and distension is not always present. 

, In the later stages the abdominal distension is often extreme, the coils of 
distended intestine are prominently discernible through the walls of the abdo- 
men, the face becomes pinched and blue, the pulse quick and thready, and 
the patient dies collapsed, often suddenly at the last. While this is the all 
but universal ending of a case of general peritonitis, when the symptoms have 
fully declared themselves, cases undoubtedly occur in which the diagnosis of 
peritonitis is made, on account of the distension and pain in the abdomen, 
which gradually improve under treatment, and finally recover. There is 
reason to suppose that cases of acute peritonitis will occasionally get well, 
even when the attack has been a general one. In other cases the symptoms 
of a local suppuration, hectic, local tenderness, and swelling, succeed to those 
of a general peritonitis. In such cases, however, there may have been a local 
peritonitis from the first. 

The following cases will illustrate some of the above remarks : 

Acute Suppurative Peritonitis. — John C. , aged 7 years. The family history was good. 
He had been a strong boy up to the time of his fatal illness. Xo cause could be assigned 
for his sickness. Four days before admission to hospital he complained of pain in the 
' stomach ; ' there was vomiting and constipation. On admission to hospital on the fifth 
day of his illness, the face wore an anxious expression, as if he was in pain ; the abdomen 
was distended and tense, and tympanitic and tender to the least touch ; his legs were 
drawn up ; he constantly vomited dark, sour-smelling, almost faecal stuff. The urine, 
drawn off by a catheter, contained albumen. All food and drink by the mouth were 



Acute Peritonitis 115 

■stopped, and he Was given ten-minim doses of tinct. opii every second houi till three doses 
had been given. He passed a restless night, yet was drowsy from the effects of the 
opium. He gradually sank, dying on the evening of the sixth day of his illness. At the 
J>ost-?nortem, on opening the abdomen, a few ounces of offensive pus escaped ; the surface 
of the intestines was injected ; the bowels were matted together with lymph ; there was no 
strangulation. The caecum and vermiform appendix were normal ; there were patches 
of intense congestion on the mucous surface of the ileum, and a sharply cut ulcer (not per- 
forating), half an inch in diameter, some two feet above the caecum. No certain cause 
for the acute peritonitis was found, unless it be assumed — which is indeed not improbable 
— that an enteritis existed in the first instance, and that the peritonitis was secondary. 

In the following case the symptoms closely resembled acute obstruction 
of the bowels from strangulation : 

Acute General Peritonitis. — John C. , aged 9 years, was healthy up to February 9, 
when he was injured by a blow in the abdomen ; but the injury does not seem to have 
been very severe. He complained of pain in the belly, and vomited the same evening. 
He continued to vomit five or six times a day till his admission to hospital (under 
Dr. Hutton) on the fifth day of his illness. He had passed nothing per rectum except a 
small stool after an enema, and it was supposed he was suffering from an intussusception. 
•On admission his face was flushed, the eyes sunken ; the abdomen was tightly distended, 
the coils of intestines being plainly seen. He complained of paroxysms of pain in the 
abdomen. He vomited faecal matter shortly after admission ; there was pain on deep pal- 
pation in the right iliac fossa, but no marked tenderness. Full doses of opium were given. 
The next day (the sixth of his illness) it was thought advisable to make an exploratory 
opening into the abdomen (which was done by Mr. Wright) ; the intestines were deeply 
■coloured, and matted together with lymph ; no constricting band or invagination was de- 
tected ; the wound was closed and a drainage tube inserted. The boy gradually sank, and 
died suddenly the next day. At the post-mortem a general acute peritonitis was found ; no 
cause for it was made out after a careful search. 

In the following case, related by Sanne, 1 acute peritonitis was accompanied 
by diarrhoea : 

Acute Peritonitis : Diarrhoea. — A boy of 14 years, who had always enjoyed good 
health, was seized with shivering and headache. On the third day he had diarrhoea and 
pain in the abdomen, followed by vomiting, distension of the abdomen, and great tender- 
ness ; the vomiting continued, so that not only bile but also the contents of the small 
intestines were ejected. Death took place on the fourth day. At the autopsy a general 
sero-purulent peritonitis was found, without any other lesion. 

In the following case the peritonitis was secondary, occurring in the 
course of scarlatinal nephritis : 

Acute Nephritis: Peritonitis. — Sarah W. , aged eight years, was attacked with scarlet 
fever, the initial symptoms being vomiting, high fever, and rash. She was admitted to 
hospital on the third day. The tonsils were sloughy ; there was much glandular enlarge- 
ment and high fever. The temperature vai ied from ioo° to ior6° F. till the twelfth day, 
when it reached 102 "6° F., and a trace of albumen appeared in the urine. On the thir- 
teenth day the temperature was 104° F., and only two hundred ami fifty cubic centimetres 
of urine were passed. From the fourteenth to the sixteenth day the urine passed was only 
from seventy to one hundred cubic centimetres daily ; urine contained fibrinous and epi- 
thelial casts. Eighteenth day, vomiting, temperature 103° F. ; only seventy cubic centi- 
metres of urine. Nineteenth day, no urine passed ; severe abdominal pain, respirations 
shallow and thoracic, abdomen distended ami tense. Twentieth day, temperature 98 to 
99 F., patient collapsed. Twenty-first day, death. At the autopsy a general sero-purulent 
peritonitis was found ; pleurisy of left lung ; acute glomerular nephritis. 

1 Barthez et Sanne, Traiti.des Malaa ■ vol. ii. p. 6ai. 



n6 Diseases of the Digestive System 



Acute Peritonitis. — Boy, 13 years, said to be delicate, but never ailed anything. He 
played with his brothers on Wednesday afternoon, tumbling about on the floor — no definite- 
history of a blow. Thursday he did not eat his breakfast, and said he felt sick ; vomited 
several times during the day, and was thought to be upset from a disordered stomach. 
Friday morning vomited, and in much pain ; bowels acted slightly ; not much distension ; 
child died same evening, 6 p.m. Post-mortem, Monday, July 29, 1889. — Some decom- 
position ; omentum normal ; surface of small intestines intensely injected, most marked 
below umbilicus ; some lymph, not excessive quantity ; bloody serum between intestines, 
a few ounces in pelvis. Vermiform appendix : external surface injected ; no evidence of 
past inflammation. Slitting up of intestines showed them to be normal, except the lips of 
the ileo-caecal valves, which were injected ; the appendix seemed thickened and cedematous, 
and contained some mucus only. Lungs were normal ; heart also normal ; the blood 
dark and fluid, and there were small extravasations of blood on the surface of the heart. 
In this case the boy died in two days from acute peritonitis. Xo cause could be assigned, 
unless it resulted from a blow when playing with his brothers the day before he was taken 
ill. There was no bruising of the abdominal wall. 

In the following case the cause of the peritonitis was doubtful, but there 
is no doubt it was very extensive, and it is a good illustration of the value of 
operation even in extreme cases. This boy was dusky and so ill that we 
hesitated to operate at all. 

Acute Peritonitis: Operation, Recovery. — Fred A., aged 12^. Six weeks before 
admission was kicked by a horse in the right side of the abdomen. He was apparently 
not much hurt, and was allowed by his doctor to get up on the following day. Five 
weeks after the accident, on May 27, 1894, he had slight abdominal pain, supposed to be 
due to eating cucumber. Vomiting and pain soon followed, and tenderness in the right 
iliac fossa a day or two later. The pain spread upwards, vomiting increased, and extreme- 
tenderness appeared in the left hypochondrium, with collapse. He was admitted on 
June 4. At that time he looked very ill ; anxious face ; pulse small ; abdomen full, moves 
very little with respiration ; legs moved freely ; abdominal walls rigid, tenderness most 
marked on left side ; nothing specially to be felt on right side. A few hours later, face 
dusky and blue ; rectal examination revealed greater resistance on the left side than on 
the right. The abdomen was opened in the middle line below the umbilicus, and a large 
quantity of faecal pus escaped. The abscess filled up the left iliac fossa, and appeared 
circumscribed, but there was resistance in the right side also. He gradually improved ; 
the quantity of pus escaping from the tube and its foetor lessened, and though for some time 
there was tenderness in the right iliac region, he steadily got well, and was heard of in 
good health four or five months later. 

Diag?iosis. — A pleurisy of the base of one or other of the lungs is often 
mistaken for peritonitis, as the sharp stabbing pain is apt to be referred to the 
abdomen where the intercostal nerves terminate. In such cases, especially 
if the pleurisy involve the diaphragm, the similarity to peritonitis may be 
great, and it is common to find that hot fomentations or mustard poultices 
have been placed upon the abdomen by the friends under the idea that there is 
peritonitis. Where pleurisy exists there is no real tenderness of the abdomen 
on pressure, and the physical signs of pleurisy or pleuro-pneumonia will be 
detected in the chest. An attack of colic is not often likely to be mistaken 
for peritonitis ; in the former there is pain and distension of the abdomen, but 
no tenderness or elevated temperature. An intussusception may be mistaken 
for peritonitis ; but the attack of pain is more sudden in the former, and 
there is not often much tenderness ; the detection of an elongated tumour would 
usually decide the diagnosis. Acute peritonitis is apt to be mistaken for acute 
obstruction of the bowels, such as results from the constriction of a knuckle of 






Perityphlitis 1 1 7 

"bowel by a band. The distension of the intestines with flatus, the vomiting 
■of sour-smelling intestinal contents, as well as complete obstruction to the 
passage of wind, maybe present in both ; there may be little tenderness, and 
but slight or no fever. The diagnosis may be very difficult or impossible, 
though the history of the case, the absence of faecal vomiting, and the less com- 
plete obstruction to the passage of both flatus and faeces in the case of perito- 
nitis, will usually help the decision. It is hardly necessary to add that it is only 
in some cases of acute peritonitis that the difficulty exists, as usually the pain, 
tenderness, and distension of the intestines are diagnostic of peritonitis. 

Morbid Anatomy. — The tendency to pus formation, which all inflamma- 
tions in children exhibit, is noticeable in peritonitis, as in acute cases the 
fluid found in the peritoneum is thick and turbid, or it may rank as pure pus. 
The amount of lymph and fluid varies in different cases ; pus or turbid 
serum will often be found in meshes of lymph between the coils of intestines, 
-a larger collection being present in the pelvis. In all cases of apparent idio- 
pathic peritonitis, a careful search should be made for a local starting point ; 
the caecum, mesenteric, and retro-peritoneal glands being carefully examined. 

Prognosis. — This is always grave ; the more acute the symptoms, the 
more rapidly the fatal result occurs. The prognosis in any case mostly 
depends on the diagnosis, for, if acute general peritonitis is present, a fatal 
result is almost certain. 

Perityphlitis. Appendicular Peritonitis. — Instead of a general peri- 
tonitis taking place, a local inflammatory action may be set up, which results 
in simple inflammatory induration going on in many cases to the formation 
of an abscess, or a- general peritonitis may supervene. The commonest 
local peritonitis is a typhlo-peritonitis or perityphlitis as it is generally 
called. The caecum is especially apt to be the seat of irritation, a peculiarity 
•which it doubtless owes to its being a cul-de-sac, in which foreign bodies or 
impacted faeces are apt to lodge, and give rise to various forms of trouble. 
Pins, fish bones, cherry stones, are apt to lodge in the caecum, and gravitate 
into the caecal appendix, and though the latter is not normally traversed by 
the intestinal contents as they pass downwards, concretions are likely to 
form from the deposition of faecal particles, inspissated mucus, phosphates 
-of lime, and other salts. As a result, ulceration of the caecum or appendix 
is very apt to take place, and a perforation to be followed by a local or 
.general peritonitis. In the majority of cases it is now well recognised that 
in most cases the mischief begins in an inflammation of the appendix due 
either to retained secretion or to the presence of some solid matter which 
may be formed in the appendix, or enter it from the bowel ; occasionally there 
is tubercular disease of the follicles of the appendix, but this would give rise to 
more chronic symptoms. The symptoms presented by perityphlitis in the 
-child resemble those present in the adult. The attack may begin with 
diarrhoea and perhaps vomiting, with more or less obscure pain and tender- 
ness in the abdomen, and feverishness. It is often extremely difficult to 
localise the pain and tenderness in a small child, and it may be quite im- 
possible at first to refer the tenderness to any one spin, especially as the 
abdominal muscles are apt to be rigidly contracted, and the child 
directly it is touched. The state of the bowels \ aries, sometimes being relaxed, 
.at other times obstinately constipated. In the course of a few days, during 



1 1 8 Diseases of the Digestive System 

which time the pyrexia continues, if a satisfactory examination can be made,, 
more or less resistance may be detected by palpation in the iliac or lumbar 
region, and a dullness on gentle percussion, though this may be masked by 
the distension of the small intestines. The patient may now, especially if 
he has been judiciously treated, gradually improve, and all pain and tender- 
ness disappear in the course of a week or two. On the other hand, the 
tenderness may increase, a distinct hardness and induration may be felt in 
the right iliac region, the right leg is drawn up, and the child cries with 
pain if it is moved. The subsequent course of the attack is uncertain : there 
may be a gradual subsidence of all the symptoms, or if the abscess is not 
opened, the hectic fever may continue, the child gradually emaciate, while 
the pus which has been formed is making its way to the surface, and the 
abscess may point in the iliac region, may discharge into the bowel, or, in 
rare cases, into the bladder or vagina. Faeces may be found in the pus dis- 
charging from the iliac abscess, and a faecal fistula result, or all the signs of 
general peritonitis, abdominal distension, extreme tenderness, and collapse., 
may come on. 

The diagnosis of perityphlitis is often by no means easy, and yet of 
much importance, inasmuch as a mistake in diagnosis may readily cost a 
life. In the early stages, the diseases most likely to be confounded with it, 
especially in small children, are coprostasis or accumulation of hardened 
faeces in the caecum, and invagination of the intestines : in a later stage, 
when the patient is seen for the first time after an abscess has formed, there 
may be uncertainty as to the source of the pus. Children who have just begun 
to run alone, and are able to make frequent excursions into the kitchen, or 
who are fed on all sorts of indigestible food, are especially liable to suffer 
from an accumulation of hardened faeces in the caecum, which may set up 
more or less irritation, and give rise to symptoms exceedingly like those of 
a perityphlitis. There is distension of the abdomen, colicky pains, vomiting, 
slight feverishness, constipation, or, on the other hand, diarrhoea ; and it 
must be borne in mind that looseness of the bowels is quite compatible with 
a loaded caecum or large intestine. It may be possible to detect a faecal 
tumour in the right lumbar region. The diagnosis in a fretful, spoilt child 
may be exceedingly difficult, but the symptoms of impacted faeces in the 
caecum will be rather those of colic, the pain coming on spasmodically, with 
no pain or tenderness in the intervals ; while in perityphlitis the pain will 
be constant, and the tenderness on deep pressure unmistakable. In any 
given case it is far better to err on the safe side, and to mistake colic for 
typhlo-peritonitis, than to fall into the far more serious error of dosing a child 
suffering from a local peritonitis with purgatives and enemas. An ileo-caecal 
invagination with its symptoms of sudden obstruction of the bowel is probably 
not very likely to be mistaken for perityphlitis ; the sudden attack in an 
infant in perfect health, the colicky pains, the straining, and passage of blood 
and mucus, and the presence of a painless tumour, would in most cases 
prevent a mistaken diagnosis. To make a diagnosis, an examination under 
chloroform may be necessary with the finger in the rectum. 

Peritoneal Abscess. Intestinal Fistula. — Apart from the suppura- 
tion which is liable to take place as the result of a typhlo-peritonitis, other 
abscesses are liable to occur in the abdomen, due in the majority of cases to 



Peritoneal A bscess 1 1 9 

glandular inflammation and originating in the mesenteric, retro-peritoneal, or 
rectal glands. Local abscesses may also occur as the result of a blow or 
following a perforation of the intestine in typhoid fever or tubercular ulcera- 
tion. As an instance of a glandular abscess in the abdomen the following 
case may be taken as an example : 

Abdominal Abscess: Discharge of Pus at Umbilicus. — A girl of seven years of age 
was admitted to hospital, having suffered for thirteen days with pain in the abdomen, 
fever, and vomiting. On admission there was some dullness below the umbilicus and 
great tenderness ; the temperature varied from ioo° to 102 . The day after the umbilicus 
became prominent and the skin red ; it gave way and pure pus was discharged. The 
wound continued to discharge for some time — on one occasion a cheesy mass was removed 
from the sinus, followed by a fresh discharge of pus ; the sinus finally closed on the forty- 
eighth day. At the end of ten weeks the girl was fat and strong ; there was some indura- 
tion, but no pain or tenderness below the umbilicus. On one occasion there was some 
pus in a stool. 

In another case, that of an infant, seen with Dr. Noble, of Kendal, it was 
noticed a week or two after birth that the abdomen was more rounded and 
distended than usual. When five weeks old the abdomen was intensely dis- 
tended, shiny, with enlarged veins on the surface, and with redness and 
protrusion of the umbilicus ; the abdomen was resonant all over, and nothing 
could be felt on palpation. A few days later the skin at the umbilicus gave 
way, and pus discharged freely. The infant a few days after died in con- 
vulsions. A large abscess cavity was found at the autopsy, and caseous 
mesenteric glands. 

In several cases which have come under our notice, with somewhat 
similar but more chronic symptoms, there has been evidence that an abscess 
had formed, probably in a mesenteric gland, and had opened into the bowel, 
pus being discharged with diarrhceal stools. Other cases occur which are 
by no means so satisfactory in their terminations as the above, being in 
many instances associated with a chronic tubercular peritonitis or mesen- 
teric disease. There are symptoms of abdominal trouble, attacks of vomiting 
and diarrhoea, hectic fever and wasting, an induration and at length an in- 
flammatory blush around the umbilicus ; the latter becomes perforated and 
pus discharges. Frequently, sooner or later, the discharge becomes faecal 
from the presence of intestinal contents, a fistulous opening having become 
established. In the majority of such cases the abscess apparently originates 
in a mesenteric gland, an abscess cavity is formed which is surrounded by 
coils of small intestine matted together, and the abscess opens both at the 
umbilicus and into the bowel in some part of its course ; but as such cases 
are mostly chronic, opportunities for ftost-mortcm examinations are not 
frequent, and when an opportunity presents itself there is so much matting of 
parts that it is difficult to make out the origin of the abscess. 

The following case illustrates this difficulty : 

Abdominal Abscess: Feecal Fistula. — A girl of lour years of age was in hospital, June 
1879, with obscure abdominal symptoms, hectic and wasting ; in the following December 
she was admitted with a sinus at the umbilicus, discharging pus and intestinal contents, 
an abscess having broken ten weeks before, The fistulous opening continued 10 discharge 
pus and liquid yellow gaseous faeces till her death in October [880, At the/, 
the liver and spleen were lardaceous. The umbilical sinus was connected with an al - 
cavity containing one or two ounces of pus and laves, and surrounded on ail sides bj 



120 Diseases of the Digestive System 

intestines matted together ; this cavity communicated with the ileum a foot and a half 
above the caecum by two openings large enough to admit a little finger. On the peritoneal 
surface of the small intestines were cretaceous nodules, apparently the remains of a past 
tubercular peritonitis. In the ileum were many cicatrices and calcareous remains of old 
ulcers and cheesy solitary glands. 

In this case the perforation of tubercular ulcers or the suppuration of 
mesenteric glands had been the cause of the abscess and fistulous openings. 
Jn several cases coming under notice the fistulous openings have closed up 
permanently, one after discharging for seven months, and in some others 
the fistulous opening has closed, but the patient died of general tuberculosis. 

Treatme?it. — As soon as the diagnosis of acute peritonitis is established 
.no time must be lost in administering opium in some form or other, the dose 
being repeated so that not only is the pain relieved but the child is rendered 
drowsy. The narcotic may be given by the mouth or by subcutaneous injec- 
tion. For a child of from one to two years, two or three minims of the 
-tincture may be given and repeated every three hours ; for a child of from 
five to ten years, five to eight drops, its effects being carefully watched. 
Hot fomentations should be applied to the abdomen ; some, however, prefer 
the application of ice — the former is much more comforting to the patient. 
If the vomiting is severe, all food by the mouth must be stopped and only 
small quantities of ice allowed ; in many cases the vomiting and conse- 
quent distress of the patient is maintained by giving large quantities of 
fluids, such as milk and beef tea. Small enemata of beef tea and brandy 
may be given by the bowel, but it must be borne in mind that large 
enemata of any sort are liable to do harm by setting up peristalsis of the 
bowel. Free stimulation with brandy, champagne, or ether, must be resorted 
to in the last stages. In typhlitis and other local forms of peritonitis, the 
same treatment must be carried out — all forms of laxatives and enemas must 
be condemned as likely to aggravate the inflammation : rest in bed, opium 
fomentations, small doses of opium and belladonna by the mouth, the most 
restricted diet, the food being given in the most digestible form and in small 
quantities. As long as the slightest pain or tenderness is present, the most 
complete rest must be maintained and all purgatives and enemata avoided. 
The formation of an abscess must be carefully watched for, and surgical pro- 
ceedings taken without delay if there is any indication of suppuration. 

Since acute purulent peritonitis is practically certainly fatal if it becomes 
g-eneralised, it is of the utmost importance to provide an outlet for a localised 
abscess rather than allow it to go on and rupture into the general peritoneal 
cavity. Hence, as soon as it is clear that a local form of inflammation is not 
subsiding under medical treatment, the safest course is to carefully cut down 
upon and let out the matter. In perityphlitic abscess (' appendicular perito- 
nitis'), when with fever there is local pain, tenderness and induration and 
drawing up of the leg, an incision should be made just internal to the anterior 
superior spine of the ilium and the successive muscular layers divided until 
the neighbourhood of the abscess is made clear either by the sense of fluc- 
tuation or by the oedematous condition of the tissues : a director is then 
thrust in the direction of the suspected cavity, and if pus appears the opening 
is enlarged with dressing forceps and the cavity drained and treated on 
ordinary principles (antiseptics being used unless the pus is foul). There is 



Chronic Peritonitis 121 

little danger in such an operation ; even if no abscess is met with and the 
peritoneal cavity is opened, no ill result is likely to follow, while the danger 
of rupture of an abscess into the general peritoneal cavity is very great. 
Local peritoneal abscess elsewhere is much more uncommon, though it may 
be met with on the left side (perisigmoid abscess), and this can be made out 
at times by rectal examination. The treatment is that of the perityphlitic 
condition. It is of little importance in such cases to make out whether the 
abscess is really a local peritonitis or a collection of matter in the cellular 
tissue outside the peritoneum, since, if peritoneal, it is usually completely 
shut off by adhesions from the general cavity, and there is no fear of pus 
flowing from the wound into the peritoneum. Local abscesses elsewhere 
must be treated on similar principles. Should a general purulent peritonitis 
already exist, the question of treatment is more uncertain and the prospect 
far less hopeful; there is, however, little doubt that the right course is to 
open the abdomen, wash it out with some unirritating antiseptic, such as 
boracic lotion, and drain the peritoneum. Should there be general faecal ex- 
travasation from perforation of the caecal appendix, or from a typhoid ulcer, 
the case must be looked upon as well-nigh desperate ; the attempt, however, 
may be made to expose the perforation, suture the intestine, and in the case 
of the appendix remove it and close the end. Cases of iliac abscess are 
common, and operation is almost always successful, and though it may be 
said that these are a different class altogether from the local peritonitis group, 
it is difficult to distinguish between the two, and there is certainly a risk of 
perforation into the peritoneum. In appendicular abscess nothing more 
should be done than simple incision and drainage ; no attempt should be 
made to remove the appendix or look for a cause of the suppuration except 
that the finger may be gently passed into the abscess and any foreign body 
removed. We have several times found a faecal concretion lying loose in one 
•of these cavities. The greatest care must be taken not to break down the 
wall of adhesion round the abscess. The opening of a local appendicular 
abscess is in our experience almost, if not quite, always a successful operation, 
but it is of course far otherwise if the suppuration has been from the first, 
or has been allowed to become general ; in such a case, too, a full search 
must be made for the source of the trouble, and an attempt made to remove 
it, whether by ligature and excision of a perforated appendix, or such other 
means as the particular case may require. {Vide also pp. 125 and 135.) 

In cases of recurrent k appendicular peritonitis' removal of the appendix 
is undoubtedly the proper course to pursue, since life is in constant danger 
as long as the source of the mischief remains. 

Chronic Peritonitis. — Chronic peritonitis is a comparatively common 
affection during childhood, and in the vast majority of cases is tubercular. 
A few cases of chronic non-tubercular peritonitis in which the diagnosis has 
been confirmed by a post-mortem have been recorded, notably one by Henoch 
which ran a course of six weeks ; at tint post-mortem cloudy fluid and orga- 
nising lymph were found in the peritoneal cavity. This case seems to have 
originated in ablow. Cases also not infrequently occur in practice o\ chronic 
peritonitis with ascites, in which there is no evidence of tubercle in any organ, 
and which completely recover ; this, however, is no bar to the acceptance o( 
Ihe belief that such are tubercular, as there is ample post-mortem evidence 






122 Diseases of the Digestive System 

to show that tubercles and lymph on the surface of the peritoneum may be- 
come cretaceous or be converted into fibrous tissue. Two forms of chronic 
tubercular peritonitis are met with in practice, in which for the most part a 
well-marked clinical difference exists, one distinguished by the large amount 
of ascitic fluid and in which probably ascites is the only symptom present, 
and the chronic cicatrising form in which there is induration and thicken- 
ing of the great omentum and a matting together of all the abdominal organs 
with little or perhaps no fluid. The same tubercular process is going on in 
both cases, but produces in one a large amount of effusion, in the other less 
or perhaps no fluid, but the effusion of lymph and its gradual organisation 
and cicatrisation. 

Ascitic Form. — Chronic peritonitis is by far the most common cause of 
ascites, or rather dropsy commencing in the peritoneal cavity during child- 
hood, while, as well known, some form of portal obstruction is the commonest 
cause in adults. Ascites due to chronic peritonitis is not common during 
the first year of life ; not that it does not occur, but the infant dies before the 
chronic stage is reached. It is not uncommon during the second year of 
life, and occurs with some frequency up to and beyond puberty. There is 
generally a history of pain in the abdomen of a more or less obscure kind 
which has been regarded as due to indigestion, probably also bothfeverish- 
ness and diarrhoea, and then the belly begins to swell. In some cases the 
enlargement of the abdomen is the first symptom which leads the friends to 
think anything is wrong with the child. On examination a rounded and dis- 
tended abdomen is found, there is dullness and fluctuation to be felt in the 
flanks if the patient is lying on his back ; while there is a more or less ex- 
tended region of resonance around the umbilicus where the distended small 
intestines are buoyed up to the surface. The fluid may, however, be localised 
by adhesions. The abdomen is often greatly distended, the skin tense and 
shining, the abdominal veins enlarged and tortuous, and in young children 
the skin at the umbilicus is protruded, and contains fluid which can be pressed 
back into the abdomen. There is mostly complete absence of pain and ten- 
derness,, the disease is frequently feverless during the greater part of its 
course, and the patient looks rather as if he were suffering from ascites due 
to some obstruction in the portal system. The course of the disease is essen- 
tially chronic, and recovery by no means hopeless, as there are not a few 
recorded instances of complete and permanent improvement taking place. 

Thus in one case a girl, aged 13 years, who was in hospital for some 
five months, and from whom eight to nine pints of ascitic fluid were re- 
moved through one of Southey's canulas, completely recovered, and was 
four years after a strong girl, supporting her mother and family by her work. 
In several similar cases we have seen recovery take place ; one suffered from 
a tubercular testis which discharged through the scrotum and healed. On 
the other hand, such children are apt to be carried off by a tubercular menin- 
gitis, or the mesenteric glands become cheesy, or a tuberculosis of the lungs 
takes place. In any case it will, of course, be necessary to carefully examine 
the lungs, and a long-continued hectic and wasting would suggest a more 
extended area of tuberculosis. In cases which end in recovery there is 
probably a matting together of the intestines, and frequently more or less 
induration may be felt about the great omentum or caecum. In cases which 



Tubercular Peritonitis 1 2 3 

are of long standing it occasionally happens that a perihepatitis with more 
or less cirrhosis of the liver takes place. This was the case in a boy of 3^ 
years who was admitted to hospital under the care of Ur. Hutton, with ascites.. 
oedema of the feet and ankles, jaundice and enlarged liver ; at the post-mortem 
the liver weighed 15 oz., the capsule was thickened and the surface was 
irregular and granular ; on section there was a great excess of fibrous tissue,, 
and old and recent peritonitis and tuberculosis of the lungs. 

Cicatrising Form. — In many cases of tubercular peritonitis there is little 
or no ascites from first to last, but lymph is effused on the surface of the 
peritoneal covering of various organs, and if the patient live long enough,, 
fibrous adhesions are formed. On the post-mortem table, local or general 
peritonitis is frequently found in children dying of tuberculosis ; thus, out of 
105 post-mo?'tems of tubercular children made during the four years 1882-85,. 
there was peritonitis in 38, though in a comparatively few of these was the 
peritonitis an early and important lesion. While this form of peritonitis is 
mostly chronic, yet some cases run a more active or subacute course. The 
early symptoms are pain in the abdomen, mostly referred to the umbilicus, 
often attacks of sickness and diarrhoea, hectic, and the presence of induration 
or irregular-shaped masses felt through the abdominal walls. The amount 
of tenderness on pressure differs greatly, being most marked in the acuter 
cases, and being absent in the chronic ones. But in cases wasted and ex- 
hausted by acute disease, even a purulent peritonitis may be present without 
any pain or tenderness. The state of the abdomen varies, it being sometimes 
distended with wind, at other times more or less retracted ; often no distinct 
tumour can be felt, but on very gentle percussion a distinct loss of resonance,, 
or a muffled resonance, may be detected over the umbilical region in conse- 
quence of the thickening and induration of the great omentum, or a resist- 
ance may be felt on palpation, or hard irregular tumours can be detected, 
the result of matting together of the omentum or intestines. Hectic fever is 
mostly present, the temperature rising to 102 or 103 at night and falling to 
normal in the morning, and more or less general wasting of the body ensues ; 
but the amount of fever and wasting present will depend upon the extent to 
which the mesenteric glands and thoracic viscera are affected. Diarrhoea is 
not usually a marked symptom unless tubercular ulceration has taken place. 
The subsequent course of these cases differs much ; in the minority, after 
several months of hectic, improvement slowly sets in and the patient improves. 
for a time at least appearing fairly well. In the majority the fever continues. 
the wasting becomes more apparent, diarrhoea, and perhaps cough, comes on 
and the child sinks. In others, the lungs remain free to the end, but mesen- 
teric disease ensues, ulceration of the bowels takes place, perhaps local abdo- 
minal abscesses form, and the liver, spleen, and kidneys become lardaceous. 
In only four of the thirty-eight cases of fatal tubercular peritonitis mentioned 
were the lungs and mediastinal glands found entirely free from tubercle. 

Prognosis. — The course of chronic tubercular peritonitis is usually long, 
unless some intercurrent disease, as tubercular meningitis, supervenes. 
Children may be under observation for main- months, with either ascites or 
induration of the omentum, with more or less hectic, and with no evidence 
of any active disease o( the lungs, and finally to all appearance completely 
recover. On the other hand, the onset of diarrhoea, hectic, progressive 



5 24 Diseases of the Digestive System 

emaciation, and cough, with evidence of lung mischief, points to the exist- 
ence of more or less generalised tuberculosis, which necessarily shortens 
the duration of the illness. Albuminuria, as pointing to lardaceous disease, 
would be of bad omen. 

Diagnosis. — When a child is presented with an ascites which has made 
its appearance gradually without pain or fever, it is perhaps not unnatural to 
attribute the collections of fluid in the abdomen to obstructed portal circu- 
lation. In an adult the commonest cause of ascites is cirrhosis of the liver, 
in a child by far the most frequent cause is chronic tubercular peritonitis. 
In a given case it may be quite impossible to make a certain diagnosis, inas- 
much as for a while the ascites may be the only symptom present ; there may 
be a complete absence of pain or tenderness, the most careful palpation may 
fail to detect any induration of the omentum. The bowels may float up and 
cause a resonant note on percussion at the umbilicus when the patient is on 
his back, the resonance shifting to the flank which is uppermost when he lies 
•on his side. It may be impossible to feel the edge of the liver, or map it out 
by percussion. In other cases, however, there will be less difficulty, for 
there may be hectic fever, or diarrhoea, or abdominal pain and tender- 
ness, or after paracentesis lumps or masses of induration may be felt. A 
family history of tuberculosis would naturally favour the view of tubercular 
peritonitis ; and occasionally the presence of a cheesy deposit in a testis will 
■decide the diagnosis. The fact that the fluid is encysted is in favour of 
•tuberculosis. 

Morbid Anatomy. — Fluid varying in quantity will be found in a few 
cases ; it may be clear or cloudy serum or pus, in which latter case it is 
•usually localised : it is not uncommon, on separating the intestines, to find 
small local collections of pus. Tubercles and lymph are usually present on 
the great omentum and mesentery, matting the intestines together, also 
between the liver and diaphragm and around the spleen ; where there is no 
large collection of fluid, the adhesions are frequently very extensive ; the in- 
testines and stomach may be adherent to the abdominal wall, so that on 
opening the abdomen the intestines are frequently cut into. The intes- 
tines, mesentery, great omentum, liver and spleen may be so matted together, 
partly by lymph, partly by fibroid adhesions, that it may be impossible to 
separate them. The intestines may be so adherent and bound down as 
to form bends and kinks that it is impossible to unravel. Cheesy mesenteric 
glands and tubercular ulcers will very likely be present. 

Treatment. — Any pain and tenderness in the abdomen in a child with 
tubercular tendencies should excite apprehension and never be neglected. 
Rest in bed should be enjoined, and a diet consisting of beef tea and milk 
should be given. The pain may be relieved by applications of belladonna 
and glycerine covered with cotton wool, or by fomentations. The bowels 
should be relieved by enemata and laxatives rather than purgatives. In 
the chronic stages, when the abdomen contains fluid or there is evidence of 
thickened and indurated omentum or cheesy masses, mercurial applications 
may be used. An ointment of yellow oxide of mercury (20 grains to the 
oz.), with an equal quantity of ung. belladonnas, may be used, with cotton 
wool to cover it. Lin. hydrarg. may be used, but salivation is likely to 
follow if continued for too long a time. Tonics and cod-liver oil emulsion 



Intussusception 1 2 5 

should be given. Chronic purulent peritonitis, whether tubercular or not, 
should be treated by incision and drainage, if the child's health is failing ; 
and there is good evidence to show that not only may temporary relief be 
thus given, but long lasting, if not permanent, recovery may take place as 
the result of incision. Even where the fluid is not purulent in obstinate 
cases drainage is of service ; it appears to cause adhesions and thus to 
prevent the re-collection of fluid, while at the same time cicatrisation takes 
place. We have little doubt that, in all cases of tubercular peritonitis 
in which there is any considerable collection of fluid, whether purulent or 
not, the abdomen should be opened and drained as soon as it is evident that 
in spite of treatment extending over some months no improvement is taking 
place. We have successfully employed this method, and are impressed with 
its value. 

Iliac Abscess. — The occurrence of iliac abscess, right or left, is fre- 
quent in children, and the various causes of such mischief should be borne in 
mind ; the principal ones, some of which have been already mentioned, are 
caries of the spine, tubercular disease of the mesenteric glands — in this case 
the abscess is more often umbilical — disease of the hip, innominate bones, or 
sacro-iliac joint, perinephritic abscess, rare in children, and the still rarer 
cases of hydatid cysts. Empyemata, superficial abscesses and abscesses 
the result of injury, ' simple psoitis ' &c. are to be thought of in addition to 
those already described as resulting from irritation of the caecum or appendix. 
But besides all these, it is common to find iliac abscesses the cause of which 
remains obscure, and we are satisfied that in many of these cases the suppu- 
ration is simply due to inflammation of lumbar, iliac, or pelvic lymphatic 
glands, just as cervical abscesses occur from irritation of the glands of the 
neck. The source of irritation is often doubtful, but is sometimes due to the 
presence of worms or other irritating matters in the bowels ; sometimes to ex- 
tension from the more superficial lymph glands. The diagnosis can usually 
be made by careful exclusion and by the history ; rectal examination is often 
of much value, by enabling the extent and position of the abscess to be 
made out, as well as sometimes by revealing a source of irritation. These 
abscesses should be opened antiseptically and drained in the usual way : it 
will often be found that they extend for long distances upwards or down- 
wards into the pelvis. The limb on the affected side should be steadied by 
a splint or by extension. The prognosis is good, provided no permanent 
source of suppuration be present. Almost every case that we have seen 
has recovered, and we believe this is largely due to early opening of the 
abscesses. 1 

Acute Obstruction of the Bowels. — Children occasionally suffer from 
acute obstruction caused by twists in the bowel, constricting bands, impac- 
tion of foreign bodies, and internal hernia ; by far the most frequent cause 
is, however, an intussusception. 

Intussusception 

The commonest cause of obstruction of the bowels in infants is the 
presence of an invagination of the bowel. Many reasons have been given for 

1 For details of some o( thesecases we may refer to a paper in the I 
vol. i. 1884, and to the Children's Hospital Abstracts \ also Lancet, February [891, 



26 



Diseases of the Digestive System 



this somewhat frequent accident. There is no doubt that one cause is to 
be found in the great reflex irritability of the muscular coat of the infant's 
bowel ; vigorous peristalsis is easily set up, and moreover, the intestinal 
walls being thinner during infancy than in later life, an invagination of one 
portion of the gut into a lower portion more readily takes place. This is 
seen in the post-mortem invaginations so often found : the act of dying seems 
to stimulate the peristalsis of the bowels, and it is no uncommon thing to 
find on the post-mortem table many invaginations in the ileum an inch or 
two in length. In some cases an accident, such as falling out of bed, or 
some rapid movement up and down in the parent's or nurse's arms, has pre- 
ceded symptoms of an intussusception, and it is possible that a sudden 
movement might cause a toneless piece of gut to become invaginated. It 
must also not be forgotten that the infant's intestines, especially the caecum and 
colon, are more movable than those of an adult, having a wider mesentery, and 
consequently one piece of bowel is more easily dragged into another portion. 
The exciting cause of intussusception is occasionally found to be a 
polypus, or an inflammatory thickening of the caecum, or some hardened 
nodule of faecal matter which adheres to the wall of the gut and sets up 
local peristalsis. We have met with a case related below in which possibly 
.a local peritonitis causing thickening of the bowel was the immediate cause 
of the invagination. 

With regard to the frequency of intussusceptions at different ages, it 
lias been stated by Pilz that, out of 293 cases, 1 53 were in their first year, and 
of these 98 were from 4 to 6 months of age. According to Leichenstern, out 
of 122 cases, 73 were under a year old, and 49 from one to five years of age. 
It is certainly the common experience that the majority of cases occur in 
infants under a year, and that from 4 to 6 months of age is a very common time. 
In at least three-fourths of the cases in infants the invagination is ileo- 
caecal, in the minority of cases it is ileum into ileum or colon into colon. In 

the ileo-caecal variety the ileum enters 
the caecum, not through the ileo-caecal 
valve, but the caecal valves are pushed 
before it, so that the valves themselves 
occupy the lowest part, and as it travels 
downwards, more and more of the ileum 
enters, dragging its mesentery along 
with it and forming the inner tube, while 
the middle layer is formed by the in- 
verted caecum and colon, the colon also 
forming the outer layer. The layers of 
an intussusception therefore consist of 
(1) an outer layer of intestine into which 
the invagination takes place, the peri- 
toneal coat being external and the 
mucous membrane internal ; (2) a mid- 
dle layer continuous with the outer 
layer at its upper end, but turned inside out so that the mucous membrane 
is external and the peritoneum internal ; (3) an internal layer formed by the 
intestine entering the outer layer with its mesentery and vessels, and which 




Fig. 17. — Ileo-caecal intussusception, a, Ileum 
(the Intussusceptum) ; b, cut edge of window 
in colon made to show the middle layer ; 
c, colon (the Intussuscipiens). 



Intussusception 127 

becoming nipped as it travels downwards forms the stoppage. In conse- 
quence of the mesentery becoming dragged in, the included intestine does 
not lie in the centre of the containing gut, but is more or less tilted to one 
side. As a result of the invagination, the inner and middle layers become 
congested and cedematous and of a dark-red colour ; blood is extravasated 
from the congested mucous membrane and is passed per rectum. In some 
cases, lymph is thrown out by the serous surfaces and a local or general 
peritonitis takes place. In a few cases, more particularly in the ileum into 
ileum variety, sloughing may take place and the invaginated bowel be 
separated and passed per rectum, while feces may be extravasated or 
recovery take place by a process of cicatrisation. The extent to which life 
is threatened depends very largely upon the tightness with which the bowel 
is nipped and the circulation of blood obstructed, and this appears to vary 
to a considerable extent, so that death may ensue in a few hours with the 
symptoms of collapse, or, especially in elder children, where the bowel 
is only partially obstructed and the circulation of blood through it but 
slightly interfered with, the course may be chronic, going on for weeks or 
even months. 

Symptoms. — An infant of a few months who may very probably have 
suffered for a few days from symptoms of bowel irritation, suddenly begins 
to kick and scream as if in violent pain which nothing appears to relieve. It 
soon begins to vomit continuously, and strain as if it wanted to pass a stool, 
but nothing escapes but a little blood and mucus. In the intervals between 
the attacks of vomiting and colic, the infant may be tolerably quiet, but it is 
usually restless and moaning as if in pain. An examination of the abdomen 
shows it to be moderately distended and resistent, though in some cases we 
have noticed it to be flaccid, and on careful palpation in the course of the 
transverse colon, an inch or so above the umbilicus and towards the left 
hypochondriac region, an elongated tumour may be felt, which is movable, 
■and, as a rule, not acutely tender. There may be also a feeling of want of 
resistance in the right lumbar region from the absence of the caecum and 
ascending colon. In very fat infants it may be impossible to detect such a 
tumour. We must not, however, forget that if an early examination be made 
no tumour may be felt, inasmuch' as the invaginated portion of ileum may 
only have passed two or three inches into the caecum and lie too deeply to 
be felt. If it travels as far as the splenic flexure of the colon, it is tolerably 
certain to be felt. In some cases, as in one related below, no tumour was 
felt after forty-eight hours. The rectum should be next carefully explored 
with the finger, and the presence of a tumour there, which is pressed down 
when the child strains, while the withdrawn finger is covered with blood, 
would establish the diagnosis. The position of the tumour necessarily varies 
according to the length of the included gut ; but inasmuch as the colon is 
nearest the abdominal wall where it crosses the upper part of the umbilical 
region, if this part is involved, as it usually is. the tumour will be most readily 
felt here. The temperature is mostly normal or subnormal, unless there is 
peritonitis, when it may be raised a degree or two. The tumour is usually 
not acutely tender, but if the case be an acute one, or, in 01 her words, if the 
included gut be tightly jammed and its vessels strangulated, the child may 
scream on its being pressed. If the ease continues unrelieved, the vomiting. 



128 Diseases of the Digestive System 

straining, and distress continue, the child wears an anxious, pinched expres- 
sion, with sunken eyes, and dies with the symptoms of collapse. The period 
at which death takes place varies ; in infants it may be within twenty-four 
hours, more often from the third to the fifth day. 

While the above description applies to the majority of cases, it must be 
borne in mind that the symptoms are at times far less well marked, so that 
the presence of an intussusception may be overlooked ; there may be perhaps 
vomiting, colicky pains, and mucoid stools, the infant dying in convulsions. On 
the other hand, it is possible that an invagination may occur, and fortunately 
right itself before it becomes tightly impacted. 

In older children, where the ileum into ileum variety occurs, the obstruc- 
tion is mostly complete and the symptoms are those of strangulated hernia r 
or constriction of a knuckle of bowel by a fibrous band. The onset is sudden, 
the contents of the stomach being first vomited, then the intestinal contents,, 
and finally, the vomit has a distinctly faecal odour ; neither wind nor fasces 
are passed per rectum, but in some instances small quantities of mucus 
and blood. The abdominal pain is usually of an intermittent and colicky 
character : the abdomen is rounded but not tender, at least in the early stages. 
In this case a tumour is not likely to be felt through the abdominal wall, in- 
asmuch as the lower end of the ileum, which is usually involved, lies deeply 
and is probably covered by distended intestine ; though in one case re- 
ported by Hertzka, where the tumour was supposed to be due to an ileum 
invagination, a swelling was felt in the region of the navel which was three- 
inches long, movable and tender ; the child recovered. In these cases no 
rectal tumour is present. 

When an ileo-caecal intussusception occurs in older children, the course 
is usually more chronic, and the symptoms less acute. There are attacks of 
colic and vomiting with obstruction of the bowels, though the latter is not 
always complete, as there may be slimy stools passed with or without blood. 
An elongated tumour is mostly felt in the usual position, lying across the ab- 
domen immediately above the umbilicus. If strangulation does not occur, the 
case may go on for weeks or months. The cause of the obstruction in such 
cases is apt to be overlooked, as the obstruction to the passage of fasces is 
not complete, and the symptoms not acute, and the tumour felt closely re- 
sembles distension of the large bowel with hard faeces. 

Morbid Anatomy. — On making a post-mortem examination, care must 
be taken to distinguish between an intussusception which has taken place 
during life and given rise to the symptoms noted, and an intussusception 
which is post-mortem and caused by the irregular yet vigorous peristalsis 
of the bowels which may take place during the act of dying or after death. 
In the latter case the invagination involves the ileum, or at any rate the 
small gut, and there are often several of them. They are rarely more than 
an inch or two in length, are readily pulled out by gentle traction, and while 
a ring of congestion may be seen near the seat of constriction, or where the 
gut has been doubled on itself, there is no oedema or marked congestion or 
effused lymph. A post-mortem invagination does not completely occlude 
the passage of the gut. In the examination in a case of the ileo-caecal 
variety which has become strangulated, an elongated mass, dark red in 
colour, is seen lying in the course of the transverse colon continuous with it 



Intussusception 1 29 

at its lower end, while the ileum with its mesentery is seen to enter at its 
upper end ; the ascending colon and caecum will have disappeared. In 
most cases the contained gut cannot be withdrawn without tearing, as it has 
become rotten from gangrene. Its passage will, in an acute case, be com- 
pletely occluded, partly on account of the cedematous and congested two 
inner layers, partly by reason of the tilting on one side of the inner gut 
through the dragging in of its mesentery. Lymph may be found effused 
between the two peritoneal surfaces, gluing them together, and there may be 
evidence of a more general peritonitis. 

In chronic cases less congestion is seen, the bowel probably is not entirely 
obstructed, and the bowel above is generally hypertrophied and its mucous 
membrane in a condition of ulceration. 

Diagnosis. — The diagnosis in an acute case in an infant is not likely to 
give rise to difficulty, inasmuch as the sudden attack of vomiting, with pain, 
straining, and the passage of blood and mucus from the bowel, and the dis- 
covery of an elongated tumour through the abdominal wall or per rectum, 
make the case tolerably clear. We may be more in doubt if with the above 
symptoms no tumour can be felt ; but we must bear in mind that a short 
ileo-caecal invagination may be present and lie too deeply in the right lumbar 
region to be felt. But the question of the presence of an intussusception 
sometimes arises in infants who are suffering from symptoms of obstruction 
to the bowels of an uncertain origin, possibly with a certain amount of 
thickening or resistance in the right iliac fossa, which may be due to the 
impaction of faeces in the caecum or to an invagination. In all such cases, as 
long as any doubt exists purgatives should be avoided, and small doses of 
opium given to allay the pain and straining. If there is pain on deep pres- 
sure, it is better to avoid enemata, trusting rather to narcotics. In older 
children the error may be made of mistaking an ileo-colitis for an invagina- 
tion of the bowel and-vice versa (see Ileo-colitis), or obstruction of the bowels 
from other causes may be taken for intussusception. ( Vide case, p. 134.) 

Treatment. — The treatment which is to be adopted must necessarily 
vary according to the acuteness of the case and the time the symptoms have 
lasted, for if the bowel has passed into a gangrenous condition it is obvious 
that only harm can be done by mechanical treatment, which might have been 
of the greatest service in an earlier stage. The question to ask oneself before 
commencing treatment is, what is the state of the invagination ? is the gut 
tightly jammed? is it gangrenous? Unfortunately these questions are very 
difficult to answer, inasmuch as in some cases the inner layer of bowel 
becomes tightly impacted from the first, and no amount of force applied 
by distending the bowel per rectum will replace it, while in other cases 
success has attended inflation of the lower bowel with air several days or 
even a week after the onset of symptoms. Thus in a child ' aged 7 months. 
under the care of Dr. J. S. Bury, injections of oil and afterwards oi air wore 
employed fourteen hours from the commencement, but failed to reduce the 
invagination, the infant dying twelve hours later, within twenty-six hours of 
the onset ; at the post-mortem • reduction was quite impossible without 
tearing the gut ;' there was some lymph effused locally. In this ease, by the 
end of twenty-four hours, the bowel was tightly Strangulated, and neither 
1 Medical Times, Feb. 10. t88x. 

K 



130 Diseases of the Digestive System 

by injections nor abdominal section could reduction have been effected. Such 
a case is no doubt exceptional, and it would probably have ended fatally under 
any circumstances unless mechanical replacement could have been undertaken, 
or laparotomy performed within a very short time of the seizure. By the time 
the invaginated portion of the bowel has travelled along the colon as far as the 
rectum, the collapse produced, especially in a small infant, is very great, and 
the difficulties in the way of replacement are necessarily much greater than 
if only a few inches of bowel are involved. But cases appear to differ very 
much in the amount of oedema and congestion taking place in the nipped 
bowel, and consequently in the difficulty of replacement. While some cases, 
such as the one just referred to, are acute and irreducible almost from the 
first, others are reported in which the intussusception was reducible some days 
after the onset of symptoms ; in one case, reported by Dr. W. B. Cheadle, 1 in 
a boy aged 5^ years, the invagination was successfully reduced by massage and 
the injection of air on the seventh day from the onset. In another case, 
reported by F. H. Elliott.' 2 in an infant of 8 months, attempts at intervals to 
reduce the invagination were at first only partially successful, but finally 
succeeded. 

As soon, then, as the existence of acute intussusception has been ascer- 
tained, it becomes necessary to decide without delay whether the patient 
shall be left to nature, or whether mechanical means shall be employed to 
overcome a mechanical obstruction. 

Recoveries after spontaneous reduction and after sloughing have been 
recorded, but they are so rare that waiting for a natural cure means practically 
abandoning the child to almost certain death. Even if recover}' by sloughing 
takes place, the risk of subsequent stricture has to be considered. It is then 
clear that some attempt at reduction should be made, and we have the fol- 
lowing plans at our disposal for this purpose. (1) Inversion of the child, 
combined with external taxis or succussion. The child is held up by the legs 
with the head downwards, and an attempt made to draw the contents of the 
abdomen to the upper part of the abdominal cavity by kneading and 
stroking with the hands through the abdominal wall, or by sudden shaking 
movements of the child an attempt is made to dislodge the intussusception. 
It is clear that this plan can only be expected to succeed when the intussus- 
ception is small in extent and recent in formation ; it is in such cases worth 
a trial since it is unattended with danger. Chloroform should be given 
during the manipulations. 

(2) Distension of the bowel with fluid or air in the hope of pushing back 
the invagination. 3 If fluid injections are employed an enema tube fitted with 
an anal shield should be passed into the rectum, and warm water or oil 
allowed to flow into the bowel from a vessel raised above the level of the 
patient's tody. The amount thus injected must vary with the age of the 
child and the position of the intussusception ; from one to two pints is about 
the usual quantity, and a fall of from three to six feet is required. 

Inflation by air is best managed bypassing the nozzle of an ordinary pair 

1 Lancet, Oct. 23, i885. 2 Ibid. Jan. 8, 1887. 

3 Vide Mortimer, Lancet, May 23, 1891, p. 1144, for an account of experiments upon 
distension. 



Intussusception 1 3 1 

-of bellows, fitted with the pipe, into the rectum, and blowing air in till the 
tumour is felt to give way, or it is not safe to distend any further. In both 
these methods the abdomen should be carefully watched, and a hand kept on 
the intussusception tumour to feel for any change in its size or position. 

The following cases illustrate the success of these methods of treat- 
ment : 

Intussusception ; Injection of Air ; Recovery. — A fine healthy infant, 6 months old, 
was suddenly seized, on the evening of January 2, with griping pains and tenesmus. It 
had been brought up on the breast, with a bottle or two a clay of cow's milk. The mother 
was menstruating for the first time, and the infant was cutting two lower teeth. His 
mother gave him an enema with a small ball syringe, which brought away a large curdy 
stool. During the night he was very restless, vomiting frequently, and straining con- 
stantly, and at 7 A.M. passed a bloody stool with mucus sufficient to saturate an ordinary 
napkin. We saw him, with Dr. E. H. Smith, of Knutsford, next morning, January 3, 
fifteen hours after the seizure. His face was placid, not drawn or distressed ; there was 
no fever ; the abdomen was flaccid and not distended, and could be easily palpated in 
every part. On deep pressure an elongated tumour was felt ; the left end was most dis- 
tinct, and was situated in the left lumbar region, just below the ribs and near the tip of the 
spleen ; it could be traced from left to right across the abdomen for two or three inches, 
its outline being gradually lost. It was movable and not tender. No tumour could be 
felt in the right lumbar region or per rectum, but the finger, on being withdrawn, was 
covered with blood. We at once decided to reduce the invagination, which we believed 
to exist, by distending the colon by water pressure. The attempt proved a failure, as the 
water returned by the side of the catheter in the rectum without distending the colon to 
any great extent. We next tried the inflation of air, by means of an ordinary Higginson's 
syringe, the bone nozzle being inserted into the rectum ; the pelvis was raised, and the 
tumour gently kneaded, while air was forced into the bowel by squeezing the ball of the 
syringe. After four or five squeezes the tension in the colon was felt to be considerable, 
then followed a gurgling noise, and the tumour disappeared. We continued to pump 
more air in, in the hope that we might effect the complete reduction of the invagination. 
The infant seemed relieved, and went to sleep for some hours ; but towards evening the 
straining returned, and he spent a restless night. There was no vomiting ; he passed per 
rectum some flatus, blood-stained mucus, and a little curd. We saw him again next day, 
January 4. There was some distress noticeable now on his face ; he had colicky pains at 
times ; there was no tumour to be felt. A minim of tr. opii was given, and the infant 
was placed in a warm bath for ten minutes. The colon was slowly distended with warm 
water by means of a Higginson's syringe, the infant being in an inverted position ; no 
immediate effect appeared to be produced. Three hours later another minim of tr. opii 
was given. An hour later, after another warm bath, he passed a copious yellow liquid 
stool. From this time he continued to improve, though for a few days he was griped at 
times and passed small quantities of blood and mucus in his stools. Small doses of opium 
were given for a few days. 

Intussusception; Injection of Water; Recovery. — A healthy infant of 5 months, who 
was nursed at the breast for three months, and latterly fed on milk and water, was mm. ed, 
in the evening of February 7, with vomiting and abdominal pain. He had been constipated 
for some time previously, and, for a day or two, more restless than usual. During the 
night he passed some blood per rectum. He continued much in the same state during 
February 8 and 9. We saw him with Dr. Massiah, of 1 Jidsbury, on the evening of the oth. 
There was no distress visible on his face, but In- was pale ami weaker than usual. The 
abdomen was semi-distended ami flaccid ; no tumour could he felt, though we were able 
to press deeply into the abdomen. He strained at limes ; and the finger, introduced into 
the rectum, returned covered with dark decomposing blood. A minim of tr. opii was 
given, and he was put into a warm bath ; chloroform was given, and warm water injected 
per rectum by means of a Higginson's syringe. There was much straining and resistance 
tt first, but this was gradually overcome. It was evident, on percussion, that the water 

K -^ 



132 Diseases of the Digestive System 

reached the ascending colon and caecum. Having distended the bowel three times with 
the water, we resolved to wait and see the effect. After the last injection he vomited some 
stercoraceous fluid. Four hours afterwards he passed a liquid stool and made a good 
recovery. 

These plans are open to the objections, first, that there is distinct danger 
of over-distension and rupture of the bowel, as shown by the experiments of 
Bryant and others ; secondly, that they can only succeed where no adhesions 
have formed between the adjacent peritoneal surfaces ; and thirdly, that 
even if reduction does apparently take place it may be incomplete or invagi- 
nation may recur. A case of our own well illustrates this last fact. 

Intussusception; Abdominal Section; Death. — Harold T. , aged 7 months, was ad- 
mitted into the Children's Hospital, May 30, 1887, with symptoms of acute intussusception 
of three days' duration. The invagination could be felt externally in the left iliac region, 
and internally per rectum. Under chloroform inflation was employed without success ; 
ten ounces of water were then injected through an india-rubber tube three feet long, with 
the result of causing disappearance of the tumour and increase of resistance previously de- 
ficient in the right iliac area. He slept quietly for some hours, and then began to scream 
again, and the intussusception reappeared. Injection was again apparently successful, 
and the child spent a quiet night. The next afternoon the svmptoms reappeared, but 
were once more relieved by injection. The next day the general condition was worse, and, 
as it was clear that no complete reduction had taken place, abdominal section was per- 
formed, the intussusception found and reduced ; the bowel was inflamed but not gan- 
grenous, there were no adhesions, and the invagination was ileo-caecal. The child sank 
and died an hour later. 

(3) Abdominal section may be performed and the obstruction relieved by 
more direct means. The section is best made in the median line below the 
umbilicus, the bladder having been previously emptied. As soon as the 
abdomen is opened, the intussusception should be drawn to the surface and 
carefully examined. If the bowel is in good condition a careful attempt 
should be made by gentle traction to withdraw the ' intussusceptum.' Re- 
duction is sometimes best managed by squeezing the tumour and drawing 
the ' intussuscipiens ' off the ' intussusceptum,' rather than by directly pulling 
out the invaginated gut. If this can be done and the bowel is not 100 much. 
injured for recovery, it should be left to itself and the wound closed. 

Intussusception ; Abdominal Section. — In a case which we saw with Dr. Cox, of 
Eccles, his patient, a child of eightfweeks old, had symptoms of twelve hours' duration. 
With the help of Drs. J. J. and F. Cox and Hutton, an attempt was made to reduce the 
invagination by injection ; this partially succeeded, but a nodule could still be felt in the 
right hypochondrium. We therefore opened the abdomen and drew up this nodule, 
which consisted of the caecum with the small intestine entering it. At this point there 
had been evidently a previous local inflammation, since the parts were much thickened 
and indurated, and the adjacent glands Mere enlarged. The intussusception had been 
reduced, and nothing more appeared necessary. The abdomen was closed, and the 
child got quite well. It, however, unfortunately died^of pneumonia three or four weeks 
later. 

If the bowel, however, is too much injured to have a reasonable chance 
of recovery, or if the intussusception is irreducible, one of three courses must, 
be followed — either the bowel must be opened above the tumour and an 
artificial anus made, the invagination being left to itself, or the intussus- 
ception must be resected and the two ends of the gut stitched together, or 



Intussusception 1 3 3 

finally, after resection the two ends may be brought out of the wound and 
fixed to its edges, an artificial anus being made. The plan of leaving the 
intussusception alone has no advantages, inasmuch as the injured bowel will 
almost certainly act as an irritant and set up peritonitis. The plan of re- 
section and suturing together the ends of the bowel, if successful, gives, of 
course, the most perfect result ; but it is open to the objection that it is long 
and tedious, and the child is likely to die of exhaustion, and, further, there is 
danger of leakage even after the most careful suturing. If this plan is adopted, 
it is probably wise to use Senn's method of lateral anastomosis, or Barkers 
plan of resection of the intussusceptum from within the gut, or one of the many 
other modes of uniting the ends of the bowel may be employed. Of these 
that by Murphy's button is probably the quickest method ; but in the absence 
of any of the special appliances, simple direct suture by Lembert's method 
may be employed. The least dangerous course is to resect the tumour and 
fix both ends of the gut to the abdominal wound. Subsequently, i.e. after 
several weeks, should the child recover, an attempt may be made to restore 
the natural channel and close the artificial anus by the usual method. The 
ends of the bowel may either be dissected away from the edges of the wound 
and united to one another by sutures, or the ' spur' (' eperon') between them 
may be removed by the enterotome and so the aperture closed, or the two 
ends may be united by Senn's or other method. This, though a less showy 
plan and one requiring more prolonged treatment, is safer at the time than 
the other method of immediate union after resection, though in a case where 
the child appeared well able to bear the more severe operation, immediate 
union is the proper course, especially if suitable appliances are at hand. The 
utmost care in all cases must be taken to prevent the escape of the intestinal 
contents into the peritoneal cavity : this is managed by emptying the 
segment of gut dealt with before opening it, and keeping it empty by pressure 
of an assistant's fingers or a clamp, such as a pair of forceps shielded Avith 
soft rubber and fixed very lightly on the bowel, so as not to bruise it. All 
blood &c. must be carefully cleaned out of the peritoneum, and most 
surgeons will prefer to use antiseptic measures. 

Given, then, a case of acute intussusception, inversion and injection 
should first be gently tried ; x should these means be successful as shown by 
the bowels acting, well and good ; if after injection the tumour disappears, it is 
well to wait for a few hours to see whether the bowels are relieved. If, how- 
ever, the tumour does not disappear, or if, in spite of its disappearance, or of 
course in its absence from the first, the symptoms persist, immediate laparo- 
tomy with reduction of the invagination, if possible, should be performed, 
and if not reducible the tumour should be resected and dealt with by one of 
the methods mentioned. For further details, we must refer to the general 
text-books or to Mr. Treves' work on Intestinal Obstruction 

Chronic intussusception is exceedingly rare in children, except, perhaps, 
as one form of so-called prolapse of the rectum, which is really intussusception 
of the upper into the lower part of the bowel. A chronic invagination may, 
however, occur elsewhere ; its duration may be weeks or months : Treves 

1 It" injection proves successful, the child should bo kept under the influent 
and the pelvis raised above tin- Level oJ the head. 



134 Diseases of the Digestive System 






records a case of a years standing and a doubtful one of many years' duration. 
We have had a child under the joint care of our colleague Dr. Hutton and 
ourselves in which a chronic intussusception of the ileo-caecal variety existed 
for a year, and which ultimately died of faecal extravasation from gangrene 
found at the time of abdominal section. The whole tumour was soft and 
pulpy, there was intermittent constipation, no vomiting, tenesmus, or bleed- 
ing, much distension with visible peristalsis, at times, at others a flaccid 
abdomen ; no definite tumour was to be felt in the rectum or abdomen, and, 
in fact, the symptoms in this case, as in most of those on record, were very 
uncertain, and not at all characteristic of intussusception. Enterotomy or 
resection was the only thing that could have relieved this case, and if the 
symptoms were at all urgent we should recommend it in another case, reduc- 
tion of the invagination being quite impossible. The bowel in these cases- 
sometimes sloughs away as in the acute form. In the simple rectal form 
the prolapse is usually reducible, and if so can be cured by rest, avoidance of 
straining, and, if necessary, the use of the cautery as in other cases. It is 
of the utmost importance that the motions should be passed in the recumbent 
position, and should be kept soft by doses of cod-liver oil or by olive-oil 
enemata. 1 Vide Rectal Prolapse. We have recently (1895) seen w i tn Dr. 
Cox a child in whom there were symptoms suggestive of intussusception,, 
though there was no bleeding or tenesmus. There was obstruction, with a 
palpable oval tumour lying on the right side of the umbilicus, and closely 
simulating an intussusception. We, however, came to the conclusion that 
the case was one of tubercular mesenteric glands, which by pressure or traction 
caused the obstruction, and on opening the abdomen this view proved correct ; 
the tumour was a large mass of glands caseating and breaking down, and 
other enlarged glands were found. The manipulation relieved the ob- 
struction, but the child was too ill to bear removal of the glands, and died a 
few days later. 

Chronic Obstruction of the Bowels. — Reference has already been made 
to the constipation of infants and older children, due to an atonic condition 
of the colon or a chronic intestinal catarrh ; but other causes of inactive bowels 
exist which are attended with serious inconvenience, and even fatal results. 
There is reason to believe that occasionally fibrous bands, due to old, perhaps 
a fcetal peritonitis, mat together the coils of intestine, more especially the 
lower part of the ileum, and consequently check or interfere with the peri- 
staltic action of the bowels. It appears also that occasionally the sigmoid 
meso-colon and meso-rectum are shorter than usual, fixing the lower bowel, 
and perhaps more or less forming a kink at its natural curves, where hardened 
faeces may lodge and a temporary obstruction take place. A fatal case, 
which seems to have been due to this cause, is recorded by Dr. Eustace 
Smith, the patient being a boy of 8 years who died shortly after coming 
into hospital. Whatever may be the cause, cases not infrequently come 
under observation where the child has suffered from constipation all its life, 
large accumulations of faeces taking place in the colon which have to be re- 

1 For further information Mr. Hutchinson's paper in the Med. -Chi?: Trans. 1874 may- 
be referred to, also Herz, Arch. f. Kinderheilk. B. v. H. 9 and 10; the latter records six 
recoveries out of twenty cases of laparotomy at ages ranging from 14 days to 14 years. 



Chronic Obstruction of the Bowels 1 3 5 

moved by enemata, and where the bowels, if left to themselves, only act once 
or twice a week. In some of such cases an enormously dilated colon has 
been found after death with superficial ulceration of its mucous membrane, 
the cause of such dilatation being by no means clear. It must not be for- 
gotten also that a chronic intussusception may exist for many months, and 
give rise to the symptoms of chronic obstruction. A careful examination of 
the abdomen should be practised in order to ascertain the presence of a 
tumour, and to determine if possible its nature, whether due to collections of 
hardened faeces, matting of the omentum and intestines, as in chronic peri- 
tonitis, or to the presence of an invaginated bowel. An examination of the 
rectum should always be made. (See p. 127.) The possibility of obstruction 
being due to pressure of an abscess or growth in the pelvis, or to the 
presence of a foreign body in the bowel, must also be borne in mind. 

The value of rectal examination was well shown in a patient of Dr. 
Denholm's, in whom, with signs of peritonitis, no evidence at all conclusive 
could be found of the locality of the mischief till an examination of the 
rectum while the child was under chloroform was made. A mass was then 
felt filling up the pelvis on the right side, and a diagnosis of appendicular 
peritonitis, with the appendix hanging over the brim of the true pelvis, was 
arrived at. An incision as for ligature of the external iliac artery allowed 
the peritoneum to be turned forward, and the abscess was with some 
difficulty reached, and opened without soiling the general cavity of the 
peritoneum, which must have been inevitably done if the abscess had been 
sought by the usual route. The appendix was felt lying in the abscess 
cavity. The child was making a good recovery at the time of our going to 
press. 



136 Diseases of the Digestive System 



CHAPTER VIII 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 

Tubercular Ulceration of Bowel and Mesenteric Disease 

In the majority of cases of children dying of tubercular disease, tubercular 
ulcers are present in the intestines, and the mesenteric glands are enlarged 
and ' cheesy ' on section. This association of ulceration of the intestines with 
cheesy mesenteric glands is so much the rule that it is impossible to separate 
the two clinically, and it must also be remembered that anatomically the 
solitary glands and Peyer's patches are lymphatic structures. The frequency 
with which these lesions complicate phthisis or general tuberculosis is shown 
by the fact that in 103 consecutive post-mortems made at the General 
Hospital for Sick Children, Manchester, on children of all ages dying of 
tuberculosis, in 62 there was tubercular ulceration of the intestines, in 71 
cheesy mesenteric glands, in 55 both ulcers and cheesy glands existed 
together, in 7 tubercular ulcers without cheesy glands, in 16 cheesy glands 
without ulcers. These numbers, as far as the frequency of tubercular ulcera- 
tion is concerned, do not overstate the fact, as it is far more likely that the 
presence of ulcers in the intestines, especially if they are small, should 
be overlooked, than their frequency overrated. These statistics also show 
the frequent association of ulceration of the intestines and disease of the 
mesenteric glands, though this association is not constant, and one may 
be found occasionally without the other. Ulceration may exist without the 
mesenteric glands joining in the process, but there is a strong probability, 
amounting almost to certainty, that if extensive ulceration be present the glands 
Trill be found to be affected. On the other hand, it is certain that ulcera- 
tion is not the necessary precursor of mesenteric disease ; for just as a chronic 
catarrh of the nasal mucous membrane may in an unhealthy subject set up 
glandular enlargement and abscess, so a catarrh of the intestine, if long con- 
tinued, is exceedingly apt to give rise to mesenteric disease. Although 
mesenteric disease is so commonly found in children dying with a wide- 
spread distribution of tubercle, it is by no means so common to find tuber- 
cular disease beginning with symptoms of tabes mesenterica, as is commonly 
believed, for in practice it is constantly found that infants and children who 
have habitually distended abdomens, with more or less wasting, are put down 
as suffering from ' consumption of bowels.' In the greater number of these 
cases there is no mesenteric disease, but a chronic and obstinate catarrh of 
the intestines which is perfectly remediable. Besides the very frequent 



Tubercular Ulceration of Bozvel 137 

association of ulceration and mesenteric disease, chronic tubercular perito- 
nitis is a frequent complication. 

Infants and children of all ages suffer from tuberculosis of the intestines 
and glands, but it is perhaps less common before the age of one year than 
afterwards. The common cause of marasmus in infants is a gastro-intestinal 
atrophy rather than tubercular disease, such infants succumbing before the 
tubercular process is set up, though in some cases cheesy glands may be 
found. It has just been noted that in at least 70 per cent, of cases dying of 
tuberculosis, disease of the mesenteric glands was present, and in rather 
more than 55 per cent, tubercular ulceration was associated with it ; it is ot 
some interest and importance to inquire in how many of these cases was the 
tuberculosis of the intestine and glands primary, and the tubercular lesions 
elsewhere secondary ; and in how many instances the tubercular disease began 
with abdominal symptoms. A primary tuberculosis of the intestine is sug- 
gestive of infection by means of tubercular bacilli taken in food, as, for 
instance, in the mother's milk or that of a foster nurse, or the milk from a 
tuberculous cow. Direct experiments in feeding young animals with tuber- 
culous material, or milk from consumptive cows, have demonstrated the 
possibility of a direct infection taking place, though there have been many 
experiments with negative results. 

Of the 103 fatal cases of tuberculosis referred to above, in 13 or about 
12 per cent, the early symptoms were referable to the abdomen ; in a few of 
the cases, symptoms of lung mischief were absent during life, and the lungs 
were found free from tubercle, or only slightly affected ; in the majority of 
cases the physical signs and symptoms pointed during life to lung compli- 
cations, which supervened sooner or later, and at the post-mortem more or 
less extensive pulmonary lesions were found, though in some instances these 
only appeared during the last few weeks or months of life. Tubercular 
ulcers are most frequently found in the ileum, and in the large bowel, especi- 
ally in the caecum. In chronic cases they may be very extensive, with much 
matting together of different coils of intestine and of the omentum by peri- 
tonitis. The walls of the caecum are often much thickened. The ulcers, if 
recent, are sharply punched out ; if chronic, their edges are thickened and 
irregular, mostly running across the gut. The mesenteric glands when 
affected are enlarged and cheesy ; sometimes a few, at other times nearly all 
the glands seem to have undergone cheesy changes ; occasionally suppura- 
tion takes place. The ulcers may cicatrise, and by puckering the gut give 
rise to some obstruction to the passage of the intestinal contents, especially 
in the large bowel or at the caecum. 

Symptoms. — If a child of over two years of age suffers from a chronic 
looseness of the bowels, with wasting and hectic, there is a strong probability 
that it suffers from abdominal tuberculosis. This probability passes more or 
less into a certainty if it comes of a tubercular stock and presents the usual 
tubercular aspect, such as marked pallor, long curved eyelashes, and excessive 
.growth of fine downy hair upon the skin. The abdomen is usually more or 
less distended with gas, the superficial veins are enlarged, there may be 
tenderness on deep pressure, and perhaps some thickening may be felt over 
the caecum, or some matting oi the omentum. The symptoms are often 
varied according as ulceration oi the bowels, mesenteric disease, or chrome 



138 Diseases of the Digestive System 

peritonitis is extensively present. In most cases of tubercular ulceration 
there is troublesome diarrhoea, though it must be borne in mind that this 
diarrhoea in many cases completely stops for a while, or, indeed, may be 
absent from first to last. There is no special feature about the diarrhoea of 
tubercular disease ; there is a general tendency to looseness, and colic may 
come on after errors in diet, or directly after food is taken, or may appear to 
be the result of cold. The stools are mostly liquid and brown or yellow with 
an excessive quantity of mucus and perhaps streaks of blood, but too much 
stress must not be laid upon the character of the stools. The tongue is 
usually clean and red, with enlarged and congested fungiform papillae. It is 
of course necessary to carefully examine the lungs in all such cases, as any 
confirmatory evidence of tuberculosis there would be of great importance 
from a diagnostic point of view. The course of such cases is often chronic, 
and they often greatly improve for a while, probably on account of the intes- 
tinal catarrh which is present undergoing improvement, or the ulcers may 
slowly cicatrise and heal. On the other hand, there is a constant risk of a 
tubercular meningitis supervening, or some acute lung trouble carrying them 
off. Sooner or later, however, the diarrhoea, wasting, and hectic reappear, 
the child becomes more and more pallid, the abdomen more distended, the 
feet swollen, and the face puffy. The diarrhoea at the last is often constant, 
and the desire to go to stool, only a little mucus or liquid faeces passing, 
is very distressing and not easily relieved. The emaciation at the last is 
often extreme. When symptoms of abdominal tuberculosis follow on those 
of chronic tuberculosis of the lungs, the diagnosis is not difficult, and a more 
rapid course may be predicted. When the tuberculosis of the intestines 
is primary and uncomplicated with other trouble, the course may be very 
chronic, extending over several years, improvement taking place from time 
to time. 

In rare cases severe haemorrhages may occur from tubercular ulceration of 
the intestines. This takes place, as would naturally be expected, in the 
acute rather than in the chronic cases, as in the late cases thickening and 
cicatrisation takes place. We have known fatal haemorrhage from the bowel 
to take place from a tubercular ulcer of the ileum. 

In the following case there was severe haematemesis, and some dark blood 
was also passed by stool. The case was puzzling, as at the time the 
vomiting of blood took place there was nothing in the lungs or abdomen 



Acute Tziberculosis ;' Ulcers in the Jejunum ; Severe Hcematemesis. — William T. , aged 
10 )ears. He was, it was stated, always a strong boy till a fortnight before his admission, 
when he complained that he was lame in his right leg ; both knees were painful and 
swoilen. Admitted June 18. He was a well-nourished boy ; all the organs were normal ; 
his appetite was bad ; there was no diarrhoea. The right knee was swollen ; there was a 
suspicion of early hip disease on the right side. The evening temperature reached 102° ; 
the evening temperature continued raised a degree or two for a few days, and then became 
normal. He complained for the next week or two of great pain in his knee. On July n, 
after having had a good dinner, he suddenly vomited a quantity of bright blood with large 
clots, and quickly became blanched ; twice during the day he again vomited dark blood. 
There was some tenderness and resistance on the left side of the abdomen, just below the 
ribs. He remained fairly well till July 18, when he again vomited some half-pint of blood 
and mucus ; there were large quantities of dark blood in his stools. July 28. — He has wasted 



Tubercular Ulceration of Bowel 139 

much in the last few weeks ; there is no cough or diarrhoea. From this date till his death 
the temperature was hectic, varying from too to 103° ; rales were heard in his lungs, 
especially at the apices, and it was evident he was suffeiing from acute tuberculosis. He 
gradually became extremely emaciated ; there were no more haemorrhages. He never 
suffered from any diarrhoea. Death occurred September 27. At the post-mortem, both 
lungs were studded with clusters of tubercles, becoming caseous at the right apex ; the 
mediastinal glands were caseous. The stomach was healthy ; the mesenteric glands were 
swollen, but not caseous ; there were some large, recent, sharply cut tubercular ulcers in. 
the middle of the jejunum, and numerous others in the ileum and large bowel. Miliary 
tubercles on the spleen and liver. Early tubercular hip disease. 

In those cases where the mesenteric glands are chiefly affected the 
symptoms are still less definite, though this, as has been pointed out, is not 
often the case, as varying degrees of tubercular ulceration of the intestines 
and chronic cicatrising peritonitis are apt to be present. The symptoms are 
usually those of chronic intestinal catarrh, perhaps without marked diarrhoea, 
with wasting and hectic. It must be remembered that a distended abdomen 
which is chronically in this condition, with some wasting and an evening- 
exacerbation of temperature, does not necessarily mean mesenteric disease,, 
any more than the signs of a chronic pneumonia are necessarily to be inter- 
preted as the signs of tubercle ; we only infer in both cases that tuber- 
culosis exists if we get confirmatory evidence elsewhere. A history of 
tubercle in the family, the steady progress of the disease, wasting, great, 
pallor and hectic, would help the diagnosis. The supposed large glands 
should be carefully felt for, taking care not to mistake faeces in the large 
bowel or indurations of the mesentery or caecum for enlarged glands. The 
fingers should be laid on the abdomen below the umbilicus and pushed well 
in, and gently moved about ; the mesenteric glands lie deeply, can rarely be 
distinctly felt, they are movable, and of size varying from hazel nuts to 
walnuts. If the abdomen is distended with gas, even large groups of glands 
may exist, and yet not be felt. An early diagnosis is rarely possible by dis- 
covery of enlarged glands ; it is only towards the close that they can usually 
be felt, when the tonus of the abdominal muscles is diminished and the 
intestines more or less collapsed. 

Diagnosis. — A child with a temperature raised a few degrees at night, 
with distended abdomen, chronic diarrhoea, which resists treatment, and 
has produced wasting and marked pallor, is probably the subject of 
tubercular ulceration of the intestines. If, at the same time, local indura- 
tions can be felt in the region of the caecum or in other places, or if there are 
signs of tubercular disease in the lungs, the diagnosis becomes still more 
probable. Moreover, the diarrhoea probably persists in spite of liquid diet, 
rest in bed, and astringents, and is only temporarily kept in check by opium. 
Mesenteric disease is much more frequently diagnosed than discovered post 
mortem. A progressive wasting due to chronic intestinal catarrh or gastro- 
intestinal atrophy is frequently attributed to caseous degeneration o( the 
mesenteric glands, and a fatal termination is looked upon as inevitable. It 
is well, however, to bear in mind that mesenteric disease is uncommon before 
eighteen months or two years of age, ami, moreover, great wasting may be 
due to intestinal catarrh without mesenteric disease, h is but seldom that 
enlarged glands can be felt ; the diagnosis mainly depends upon thesiejis ot 



140 Diseases of the Digestive System 

tubercle elsewhere in the body and upon the family history. If there has been 
much diarrhoea with hectic, and symptoms of chronic peritonitis, followed 
by extreme wasting, there is good reason to suspect mesenteric disease. 

Treatment. — The treatment of tubercular ulceration and mesenteric 
-disease is the treatment of tuberculosis in general. Fresh air and careful 
•dieting are all-important. The special treatment consists in keeping the 
diarrhoea in check, while nourishing food easy of assimilation is being sup- 
plied to the patient. The class of foods must be selected from those which 
contain much nutriment in little bulk, such as eggs, fish, meat, fats, milk, 
rather than foods containing large quantities of starch and sugar. If there 
is but little diarrhoea, milk may be allowed in moderate quantities, but the 
.amount taken must not be excessive if much looseness of the bowels exists, 
as too much fluid taken is apt to aggravate the diarrhoea. In all stages of the 
disease minced underdone meat, whether chicken, beef, or mutton chop, is 
of great value. The child's portion may be taken from red juicy meat 
found close to the bone in a large joint of roast beef. It should be finely 
minced, cut as fine as it is possible to cut it, and gravy poured over 
it before it is taken. Of this, large quantities will be taken readily by the 
-children, some crumbs of stale bread being given with it ; but even small 
-quantities of starch are apt to disagree and give rise to flatulence. An egg 
or part of an egg beaten up in milk may be given once or twice a day. The 
diarrhoea is best kept in check by careful dieting, avoidance of more food 
than the child can digest, and if excessive, the food for a while must consist 
almost entirely of pounded underdone meat or meat juice. Small doses of 
opium combined with mercury and chalk maybe given. (F. 20, 21.) 

In the later stages small enemata of laudanum and starch may be re- 
quired, but too often the diarrhoea is quite uncontrollable. Opium fomenta- 
tions are useful. If the diarrhoea is due to the presence of indigestible food, 
laxatives such as a powder containing rhubarb and soda should be given. 
Cod-liver oil, either as an emulsion or in combination with other tonics, is 
useful in all stages except when the diarrhoea is excessive. (F. 22.) 

Congenital Obstruction of the Bowels. — It is not an uncommon cir- 
cumstance for a newly born infant to suffer from complete obstruction of 
the bowels ; passing no meconium, though the rectum may be normal, and 
.-shortly after being put to the breast it may vomit, first milk, then bile, 
and finally meconium. In the meantime the abdomen becomes dis- 
tended, the face pinched, and the infant dies in a few hours, or perhaps 
lingers for a few days. At the post-mortem various obstructive lesions may 
be found. There may be a stenosis of the duodenum, jejunum, or more 
frequently the ileum, the gut perhaps being narrowed or even reduced to a 
mere band of fibroid tissue which runs along the free edge of the mesentery 
for perhaps several inches, and opens out again into normal bowel lower 
down ; this cicatrisation of a portion of bowel may have been produeed by a 
foetal peritonitis, or it is the result of a mal-development. In the following 
case it was apparently the latter : 

Congenital Occlusion of the Duodenum (Dr. T. B. Grimsdale's case). — The mother 
was a healthy woman who had had five children previously. The first was stillborn ; the 
four others all suffered from symptoms of obstruction and died on the third day after 
birth. The sixth child appeared healthy and well nourished at birth, and for the first two 



Obstruction of the Bowels 141 

days seemed quite well. For the last two days it was a peculiar colour— a sort of orange- 
purple tint. It only vomited once shortly before death ; it was convulsed before death. 
At the autopsy the stomach and upper part of the duodenum were distended with fluid ; 
the duodenum was found to terminate in a cul-de-sac about two inches from the pylorus. 
The rest of the intestines were well formed though small ; the bile duct opened into the- 
duodenum below the obstruction. 

In the following singular case there was an obstruction of the jejunum,, 
presumably due to a fcetal peritonitis and possibly some chronic inflamma- 
tory lesions after birth : 

Congenital Obstruction of the Jejunum; Dilated Stomach and Duodenum. — W. M.,. 
aged 15 year?, seen with Mr. C. R. Graham, of Wigan. His mother gave the following 
history : He was nursed at the breast for some months, and during this time he was sub- 
ject to periodical attacks of severe vomiting ; these attacks were much more severe than 
infants are usually subject to. The vomiting began immediately after birth ; the vomited 
matters consisted of curd and bile. These attacks of vomiting have occurred at intervals 
of a week or two all his life. On more than one occasion the attacks have been so severe 
and long continued that his life was despaired of. He has vomited as much as six to 
eight pints in one night. He went, on one occasion, a voyage to the Mediterranean, but 
had to be landed on the first opportunity, as the constant vomiting had so exhausted him 
that his life was in danger. Sometimes he would suffer from colic and nausea but did not 
vomit. Errors of diet, excitement, or worry, all seemed to excite an attack. A physical 
examination showed a dilated stomach ; the abdomen was also more or less distended. 
The symptoms and physical examination pointed to a dilated stomach, secondary to some 
congenital obstruction in the upper part of the bowels. The vomiting attacks continued 
during the next four years, up to the time of his death, when he was nineteen years old. 
We are indebted for details of his last illness to Dr. Sutcliffe, of Jersey, where he died. 
He seemed in his usual health on December 6, 1890, and joined in a game of football. 
The same evening he had one of his usual vomiting attacks, which was more severe 
than usual, and Dr. Sutcliffe was sent for. When seen on December 8, he was evidently 
suffering from acute obstruction of the bowels : the vomiting was continuous, and nothing 
was passed per rectum. There was intense collapse. Death took place on the fourth day 
of his illness. Post-mortem made by Mr. Graham and ourselves : The body was that of 
a well-grown but thin youth. On opening the abdomen the small intestines were seen to 
be intensely congested and of a dark purple colour ; there was some lymph on the surface ; 
the parietal layer of the peritoneum was much injected. The whole of the small intestines- 
were evidently strangulated, there being a complete volvulus ; the last foot or so of the 
ileum was wound two or three times round the upper part of the jejunum, the latter being 
twisted on itself, so that the jejunum, mesentery, and blood-vessels were strangulated ; the 
caecum was dragged upwards out of its place. The immediate cause of death was the 
volvulus, probably the result of severe vomiting. A further examination showed the cause 
of his vomiting attacks. The stomach and duodenum were immensely dilated and hyper- 
trophied, the duodenum looking like a second stomach ; at the junction of the duodenum 
with the jejunum, the gut was bound down and surrounded by fibroid adhesions for some 
six inches, and one spot was contracted so as only to admit the forefinger. The fibroid 
mattings were presumably the result of some inflammatory k^ion taking place before bilth. 

In a few cases a twist in the lower end of the ileum has been found. In 
rare instances, a new growth or hernia has occurred, or a knuckle o\ bowel 
has been found tied up by some band or persistent omphalo-mesenteric duct. 

Obstruction of the bowels in infants a low weeks or months old may be 
due to a congenital lesion which has caused a partial obstruction, which is 
rendered complete by the impaction of hard curdy feculent matters. 

In all cases of vomiting with si^ns oi obstruction of the bowels, a care- 
ful examination of the anus and rectum should be made. 



142 Diseases of the Digestive System 

Imperforate Anus. — The lower segment of the large intestine, including 
the sigmoid flexure and rectum, is very liable to important malformations. 

In the first place there may be mere malposition, the sigmoid flexure de- 
scending on the right side or in the middle line instead of on the left ; this 
would not necessarily give rise to any inconvenience during health, and 
would be mainly of importance should there be any disease of the bowel in 
later life. 

The more immediately important conditions are the various forms of 
■obstruction of the lower bowel from want of development of some part of it, 
or the presence of abnormal openings from imperfect differentiation of the 
digestive and genito-urinary segments of the cloaca. 

Several varieties of malformation are found. There may be a well-formed 
anus, but communication between this and the rectum may be cut off by the 
presence merely of a membrane which has persisted from the time when the 
epiblastic involution dipped in to meet the intestine. {Imperforate rectum.) 
Sometimes the rectum itself is deficient altogether or for a varying distance, 
the anus also being undeveloped. In other instances the rectum is well 
formed, but the anus is absent. {Imperforate anus.) In these varieties there 
is no external opening at all, and the meconium is retained. Sometimes 
the anus is undeveloped, and the rectum, instead of ending blindly, opens 
into the anterior or genito-urinary segment, i.e. into the urethra or bladder, 
or, much more commonly in the female, into the vestibule, not into the 
vagina, as is commonly stated ; the vaginal orifice in these cases is nearly 
always in our experience seen in front of the rectal outlet. We have only 
once met with a case of the rectum opening into the vagina itself ; this was 
in a child kindly sent us by Dr. Cullingworth, who thinks it is not an 
uncommon condition. Bodenhamer, out of 287 cases, found 85 opening 
into the vulva or urinary tract, while in 53 there was no anus and the rectum 
ended blindly ; these are the two most common types. 

Occasionally a ' tablike fold of skin ' passing from the scrotum to the 
coccyx obstructs but does not close the anus (Cripps). Edge has recorded a 
more complete case where the anus was double and the rectum imperforate. 
We have met with a case where a single anus led up to a double gut above. 
Rarely there is an unnatural anus in the groin or in communication with the 
bladder, or, as in a case of Erichsen's, a fistula below the umbilicus ; scrotal, 
penile, and perineal fistulas have also been met with as well as congenital 
stricture of the rectum which was not actually imperforate. (Vide Prolapsus 
Recti.) As a less important condition mere tightness of the anus may also occur. 
When the anus is present, but there is no communication with the bowel, 
the malformation is often overlooked at first, and it is thought that the infant is 
simply constipated ; in such cases purgatives are often given and the child's 
distress much increased. Constant crying, distension of the abdomen with 
visible intestinal coils, and subsequently vomiting and collapse come on, and 
unless an examination with the finger is made and the obstruction discovered 
the child dies exhausted. On examination it will be found that the finger 
can only be passed a very short distance ; if the rectum is developed and 
there is only a membranous septum, the bulging of the gut as the child 
strains will be plainly felt, but should the bowel end higher up this sensation 
may not be distinguishable. 






Imperforate Anus 143 

Where the anus is absent and the rectum ends just above it, as according 
to Cripps it usually does, the bulging will often be readily made out, but if 
the rectum ends higher up there may be no impulse ; in such cases the peri- 
neum is narrow and the pelvic outlet smaller than it should be. When 
there is no anus the rectum is generally nearer the surface than when an 
anus is developed, but the rectum ends blindly. 

Where the rectum ends high up in the pelvis, a fibrous cord may be 
prolonged downwards in the position of the natural bowel ; this cord was 
thought by Mr. Curling to represent the rectum obliterated by intra-uterine 
ulceration ; its presence, however, is not constant. 1 

When the rectum ends in the urethra there is passage of fluid faeces and 
flatus by the urethra, together with absence of the natural orifice. Subse- 
quently, if the child survives, there is much trouble from obstruction of the 
urethra by faecal matter and from irritation set up by the decomposed urine. 
Kelsey 2 points out that if the opening is into the bladder the meconium is 
mixed with the urine, while if it is urethral the bowel contents may escape 
independently of the urine. When the rectal outlet is within the vestibule the 
bowels may be sufficiently relieved for the deformity to escape notice, and 
there may be no impairment of health ; indeed, the presence of such malforma- 
tion may remain unknown until adult life. In many cases, however, though 
the opening is sufficient for the escape of the fluid or soft faeces of child- 
hood, it is not large enough to allow the passage of solid motions, and 
•obstruction arises later on. There is no incontinence of feces in these 
patients, the internal sphincter preventing involuntary escape. 

As in so many other congenital malformations, a large number of chil- 
dren the subject of these deformities do not survive birth. Where, however, 
a living child is found to have no outlet at all for its intestinal contents, 
immediate treatment is of course necessary, although it is said that patients 
have grown up and relieved the bowels by periodical vomiting of faeces. 
As soon then as the deformity is recognised, a decision must be come to as 
to what is the best mode of relief. 

Treatment. — When a thin septum alone closes the gut a simple crucial 
i ncision, using a speculum if necessary, and subsequent dilatation with a 
bougie or the finger, is all that is required. The child, if it survives, may in 
no way suffer afterwards, though we have seen a case of a girl of 10 or 12 
years old who had been operated on in infancy and had not got perfect 
control over the bowels. 

Where the separation between the rectum and the surface is greater, 
bulging of the distended gut should be carefully felt for and an incision made 
just in front of the coccyx and carried down to the bowel, which should then 
be freely opened and brought down and stitched to the skin, unless there is 
so great tension that the stitches are not likely to hold, in which ease the 
opening should be packed with gauze to keep it patent, or a large drainage 
tube inserted. 

If no bulging can be felt, an attempt to reach the bowel should still be 
made by a similar incision, and the dissection should be carefully carried up- 
wards, keeping well back in the hollow o( the sacrum and feeling from time to 

1 Vide Parker, Path. Soc. Trans, 1884. % Archives of Pa 



144 Diseases of the Digestive System 

time for the bowel. As it is most important that the child should strain,, 
chloroform should only be given during the first steps of the operation, 
and fortunately this is the most painful part of it. With a similar object 
it has been advised to delay operation until the bowels are distended. 
If the gut is found, it should be treated as in other cases, or if it cannot 
readily be brought down, it must be left but kept patent in a similar 
way, or a tube may be kept in through which faeces can pass. Amussat 
and Verneuil resected the coccyx and lower part of the sacrum in order to 
bring the gut to the surface. 

Should it be impossible to reach the bowel from below by dissection, 
which may be carried to a depth of an inch and a half, in no case must 
any blind puncturing with a trocar in hopes of finding the gut be employed ; 
by such means there is much more likelihood of puncturing the peritoneum, 
especially as it usually descends lower than in normal anatomy. Either 
Littre ; s operation of opening the bowel in the groin or Amussats (Callisen's) 
lumbar operation must be performed. As there is some uncertainty in 
all these cases as to the course of the bowel, and as in a certain proportion 
the colon lies in the middle line or to the right side, it is wiser on the whole to do 
Littre's operation. The danger of opening the peritoneum is not so unequal 
in the two plans as might be thought, since there is often a mesentery 
in these cases, and the anus is much more conveniently placed for 
self-management in after life ; there is little choice in the matter of danger 
between the two. Littre*s operation then should be selected. The operation 
consists in making a vertical or oblique incision about two inches in length 
in the left groin above and a little external to the middle of Poupart's 
ligament ; a vertical incision is probably the best, since, if the sigmoid 
flexure does cross to the right, a slight upward prolongation of the incision 
will enable the surgeon to reach it. The abdominal wall having been cut 
through and the peritoneum opened, the distended bowel will present at the 
opening and should be picked up with forceps, and treated as in the ordinary 
colotomy operation. 1 If the child can bear the delay in opening the bowel, 
the operation should be done in two stages as in gastrostomy ; to avoid 
leakage Cripps suggests the use of a coarse thread in stitching the gut to the 
edge of the wound ; the use of a round sewing needle answers better. 

Edmund Owen has six times performed Littre's operation, twice success- 
fully ; three of his cases died from the operation being too late, peritonitis 
existing at the time. In two of the instances in which we have done inguinal 
colotomy the result was perfectly satisfactory ; the children got quite well, but 
one died some months after of bronchitis. It has been suggested that after 
opening the sigmoid flexure in the groin, a probe should be passed down- 
wards and an anus made in the natural position with the guidance of the 
probe. Owens two successful cases of Littre : s operation died after the 
performance of this second operation, but Byrd and Kronlein have been 
successful.- 

Curling's statistics and opinion are much in favour of the inguinal 
operation ; Cripps" figures are inconclusive. 3 Huguier s operation of opening 

1 Fcr a description of the operation we must refer to the general text-books. 

2 Vide Kelsey, Arch, of Pediatrics, February 1885 ; also Goede vide Cripps. 
5 Vide also Erckelen, Arch. f. Klin. Chir., Langenbeck, 1879. 



1 1 


died 


2 


5) 


14 


33 


5 


3) 


14 


3) 


1 


3) 


3 


33 



Imperforate Ames 145 

the gut in the right groin on the ground of the more frequent position of the 
colon on the right side than the left is not supported by Giraldcs' statistics, 
quoted by Holmes, where in 431 autopsies the colon was in its normal position 
in 396 instances ; in eighty of these Littre's operation bad been performed, 
and in every case the sigmoid flexure was on the left side. Atkin, of Sheffield, 
records a case in which the small intestine was opened by the inguinal ope- 
ration, the whole colon being rudimentary; 1 and our colleague, Mr. White- 
head, tells us he operated in the left loin on one occasion and found at the 
post-mortem that the caecum had been opened. 2 

We have opened a coil of large intestine by right inguinal colotomy in 
an adult, and found that it was the sigmoid flexure and not the ascending 
colon that had been secured. 

Cripps' table gives the following results : 

Of 16 cases of inguinal colotomy 

„ 3 „ lumbar „ . 

,,17 „ puncture . 

„ 8 „ resection of the coccyx 

„ 39 „ perineal incision 

„ 14 „ operation for vaginal (i.e. vulvar) anus 

„ 3 miscellaneous cases ..... 

Bodenhamer records eight recoveries out of twenty-five Littre's opera- 
tions. 

The deaths are mainly due to peritonitis, or failure of relief. 

Where there is a fistulous opening between the rectum and the bladder 
or urethra, Littre's operation should be performed, unless the gut can be 
reached from the perineum, when possibly the communication with the urinary 
tract may close spontaneously. When the unnatural anus opens in the 
vulva, in the cases we have seen it has usually been by an orifice in the side 
of the distended rectum and not by a terminal opening ; that is, the rectum has 
been pouched and projecting below the vulvar aperture. In such conditions 
a bent probe should be passed through the orifice into the gut and made to 
press against the perineum just in front of the coccyx. An incision is then 
made upon the probe, the rectum freely opened and treated in the usual 
way. Great care must be taken to keep the new aperture patent, otherwise 
it is prone to contract and the faeces continue to pass both ways. In some 
cases it is said that the vulvar orifice will contract and close of itself 
(Holmes). In our own cases we have not found this to occur, and in one of 
them we pared the edges of the vestibular opening and sutured them ; no 
union, however, resulted, and we afterwards laid open the perineum, dissected 
away the gut from the vestibular wall, stitched it carefully to the skin, and then 
sewed up the perineum, with a successful result ; the patient was about 6 
years old. In another instance we performed the same operation in a child 
of 9 months, but it died some weeks later of inanition. We have had 
a third successful case recently in which power of retention seems well 
preserved. Dieffenbach appears to have been the first to adopt this plan, 
which, however, is often called Ri/xoli"s operation. It is, we think, well tit 

1 Lancet, January 31, 1884. - Pillore advised opening theceecum. 



146 Diseases of the Digestive System 

wait until the child is two or three years old before doing the second 
operation. 

One of the difficulties we have met with in these cases is that of keeping" 
the bowels regular even when there is quite a free opening ; this we believe 
to be due to imperfect muscular action, though the muscular coat of the 
bowel is hypertrophied in some of these cases. Enemata, castor-oil emul- 
sion, and occasional more active purges are required under these circum- 
stances. Sometimes when the case is one of vulvar anus a collection of 
hard feces is found in the intestine above at the time of operation ; this 
requires removal, as the child is often unable to void it even when a good- 
sized aperture has been made. 

Deformities of the Umbilicus.— In some cases of extroversion of the 
bladder there is no trace of an umbilicus to be seen in after life, the scar 
being lost in the malformed abdominal wall. In other cases the umbilicus 
is abnormally large — that is, a considerable part of the abdominal wall 
is formed by the structures of the cord, and sloughs away when the cord 
shrivels up so that an actual deficiency of the abdominal wall results. In 
two cases of this condition we have seen that were operated upon, one by 
Mr. Howse and one by ourselves, a portion of the liver protruded through the 
opening and was covered only by the sloughing tissue. In our own case we 
dissected away the dead part and closed the abdominal opening by sutures,. 
but without success ; in a third case, under our care, the part was simply pro- 
tected from irritation and left, but this child also soon died. 1 The frequent 
presence of the liver in the hernia has given rise to the name of Hepatom- 
phalos, but the stomach and other viscera are often included in the protrusion. 
At the third month of intra-uterine life there is still a coil of intestine 
lying in the umbilical cord outside the abdominal cavity ; should this condition 
persist, a true congenital umbilical hemia is found. The importance of this- 
fact is that in ligaturing the cord the gut might be included in the ligature and 
strangulated, a mishap that has actually occurred. In slighter cases there is 
only a small protrusion standing out from the abdominal wall much like the 
end of a glove finger ; the bowel is reducible and the treatment is that of an 
ordinary umbilical hernia. In other instances, owing to persistence of the 
vitello-intestinal duct, Meckel's diverticulum remains open, and passing up 
to the umbilicus may open there, giving rise to fecal fistula, as in a case of 
our own where a ligature round the protrusion, followed by the application of 
strapping to draw together the sides of the orifice, procured closure of the 
fistula.' 2 Edmund Owen advises emptying the bowel by free purging and sub- 
sequent administration of opium, thus giving time for the fistula to close ; he 
applies a dry pad over the fistula and leaves it undisturbed. Success has 
followed this treatment, but it appears to be applicable to older children 
rather than to infants. For ftate?it urachus cV~t. vide SURGERY OF THE 
Urinary Organs, vide also Diseases of the Navel. 

Congenital hiatus of the abdominal wall may occur in other parts besides 

1 Underwood records a case of recover}- in which the treatment consisted in poulticing, 
and Tanner and others have had successful cases. In a case of Brodie's Path. Soc. 
Trans, vol. xv. , besides the hepat omphalos, there was diaphragmatic hernia with defi- 
ciency of the pericardium, and a coil of bowel lay in contact with the heart. 

- Vide Diseases of the Navel — Umbilical Polypus. 



Umbilical Hernia 147 

the umbilicus from simple failure of closure of the ventral laminae. Of this 
extroversion of the bladder is an instance. In some cases the recti fail to 
meet one another in the middle line, and ventral hernia may result with great 
weakness of the abdominal wall. 

Well-arranged pads applied by means of a belt must be employed to 
prevent protrusion, or possibly in some cases it must be justifiable to cut 
down upon and stitch together the margins of the aperture, an operation 
not of a very serious nature, and not of course necessitating any injury to 
the peritoneum. 

Umbilical Hernia. — Umbilical hernia then in children may be con- 
genital or acquired ; in the congenital form it is sometimes due to persistence 
of the fcetal condition where a coil of bowel lies outside the abdomen ; in 
other cases, as already pointed out, it is the result of failure of closure of 
the ventral laminae. 

The acquired form usually appears within the first few months of life ; in 
this case the rupture protrudes not through the centre of the scar, which is 
occupied by the fibrous remains of the vessels, but usually above it or even 
through an independent opening in the linea alba. Astley, however, believes 
that the protrusion is generally through the ring. Both forms of hernia 
are readily reducible and usually consist of small intestine ; the amount of 
protrusion varies from a mere convexity of the navel to a prominent glove- 
finger-like outgrowth. 

The treatment consists in applying a flat pad of wood or poroplastic felt 
about the size of a penny and two or three times as thick ; this pad should be 
covered with flannel and fixed over the umbilicus by a broad band of strap- 
ping encircling the body or by a soft webbing belt ; we prefer the former as 
more efficient and less likely to slip, though it is not so comfortable as the 
belt. If the pad is worn constantly for from one to three months, according 
to the age of the child, the hernia is usually ' radically cured.' In cases 
which obstinately resist treatment the orifice might be cut down upon and 
sutured. A case of irreducible umbilical hernia containing omentum was 
successfully operated on by Roocroft in a girl of 14 years ; 2 but it is clear 
that most cases of umbilical hernia in children are cured, since the condition 
is hardly ever seen in young adults. We have had occasion to close by 
operation a median ventral hernia in a child. The result was successful. 

inguinal Hernia. — Inguinal hernia is met with in childhood in the fol- 
lowing varieties : 

1. The funicular process of peritoneum remains widely open and m free 
communication with the cavity both of the peritoneum and tunica vaginalis : 
a hernia descending into this cavity is a true congenital hernia, or hernia of 
the tunica vaginalis (Teale). 

2. The tunica vaginalis may be shut off from the funicular process at the 
upper part of the testicle ; a hernia coming down into the patent process is 
called a funicular hernia, or hernia into the funicular process. 

3. When the same condition as in (2) exists, but the hernia instead of de- 
scending along the canal of the funicular process pushes down a separate 
pouch of peritoneum behind the process, the hernia is called infantile or 
encysted. The same name is given to cases where the funicular process is 

1 / meet, Augusl a, 1884. 

1 j 



148 Diseases of the Digestive System 

obliterated at the internal ring or just above the testicle, and the septum 
is pushed down and invaginated into the lower part of the process. In 
the former case, in cutting down upon the bowel from the front three layers 
of peritoneum, viz. two funicular and one sac proper, will be found in front 
of the gut ; in the second case two layers will overlie the bowel. 

4. An ordinary acquired hernia may be met with. Hernia may, of course, 
be complete or incomplete — that is, it may descend into the scrotum or only 
distend the canal or bulge at the internal ring. 

The first and second forms are much the commonest, and it is usually 
impossible to be certain which is present unless the parts are exposed by 
operation. Where the testicle is completely wrapped round by the hernia 
it is probably congenital ; where the testicle remains a distinct boss upon the 
surface of the hernia it may be funicular, though it is not by any means 
always so. We believe the funicular variety is the more frequent. Infantile 
or encysted hernia can only be recognised by operation, but it may be sus- 
pected if, after reduction of a hernia, an unusual amount of thickening along 
the cord remains, or if there is a hydrocele of the cord or an infantile hydro- 
cele in conjunction with a reducible hernia. Fortunately, an exact diagnosis 
of these conditions from one another is not of much importance. 

Hernia may develop at any age ; it is sometimes noticed immediately after 
birth ; in other instances it comes down later when, from failure of health, or 
bronchitis, or whooping cough, the muscular walls of the abdomen become 
relaxed, and are in addition overstrained by coughing, violent crying, straining 
in defalcation, micturition, &c. So common is it for straining in micturition 
to bring down a hernia, that it is quite certain that phimosis is a most fertile 
cause of rupture. 1 The presence of a calculus or worms acts in the same 
way. Hernia very commonly accompanies ectopia vesicae. 

As is well known, inguinal hernia is sometimes met with in female chil- 
dren, though not nearly so commonly as in boys. Of 112 unselected cases 
of hernia seen in our out-patient department, there were — 

In males . 57 right inguinal, 12 left inguinal, 16 double, and 9 umbilical. 
In females 4 „ „ 5 „ _ „ no „ „ 9 (? 10) „ 

Mr. Leader Williams tells us that in his experience in the Maternity Depart- 
ment of St. Mary's Hospital, Manchester, umbilical hernia is by far the 
commonest variety, and this is no doubt true of the first few weeks in life. 

Most commonly an inguinal rupture in a child contains small intestine 
with or without omentum, perhaps most commonly without. Other parts of 
the intestinal canal are, however, not rarely found. We have many times 
during operation found the caecum and vermiform appendix in a hernia, and 
not rarely the appendix can be very distinctly felt through the coverings 
without an operation.- The ovaries in girls and the bladder in either sex are 
sometimes protruded. 

Generally a rupture is easily reducible, but often it is necessary to make 
the child lie down before it readily goes back ; it then often does so sponta- 
neously. Violent crying will sometimes make it quite impossible to safely 

1 An important fact first pointed out by Mr. J. A. Kempe. 

2 Vide papers in the Brit. Med. Jour. vol. i. 1837, by Mr. F. Treves, and also by one 
of the present writers. 



Inguinal Hernia 149 

reduce a hernia, and the child must be quieted or anaesthetised before 
reduction. 

It must be remembered that, though as a rule herniae are opaque, a 
tightly distended rupture consisting only of bowel, and that full of flatus, in 
a thin-skinned child will be distinctly translucent; this fact was, we believe, 
first pointed out by Mr. Howse, and we have several times seen it. 

Various abnormal conditions may complicate hernia ; thus the testis maybe 
entirely retained or have imperfectly descended on the same side. A vaginal 
hydrocele or hydrocele of the cord may coexist with a hernia, or fluid as in a 
congenital hydrocele may distend the sac of a congenital hernia. The rupture, 
of course, may be single or double, and sometimes of a different species on 
the two sides. We have seen a 'funicular' and a 'congenital' hernia on 
opposite sides in the same child. Children the subject of hernia are un- 
doubtedly often affected with intestinal disturbance, which appears to be 
sometimes at least due to the hernia. It has, however, been suggested by 
Lane that the hernia is due to the intestinal trouble, and it is undoubtedly 
true that marasmic children with chronic indigestion and irregular and often 
constipated bowels not uncommonly have hernias which are not readily cured 
till the nutrition is improved. 

Ruptures in children are occasionally irreducible ; when this is due simply 
to straining, as already pointed out, the difficulty is easily got over, in other 
cases the hernia may be obstructed by its contents as in adults ; again, 
adhesions to the sac or to the testicle or matting together of bowel to 
bowel, or bowel to omentum, may prevent reduction. In one of our cases a 
large hernia was made irreducible by the presence of tuberculous mesenteric 
glands which had evidently enlarged after their descent, and it was only 
after removal of some of these and enlargement of the rings that the rupture 
could be reduced ; the child recovered, but evidence of tuberculosis, of course, 
remained. 

It is somewhat rare for a hernia to become strangulated in childhood. We 
have, however, met with several such cases ; they differ in no respect from 
the similar condition in the adult, but considering the extreme tenderness of 
the tissues in children immediate operation is the wisest course in preference to 
treatment by ice, &c. Elevation of the pelvis and abdomen, as well as direct 
taxis, should, perhaps, be first tried, but very gently ; we have known a 
child die of the injury done to a coil of intestine which was reduced before 
the child was seen by us, and could only have been strangulated for a few 
hours. The youngest cases with which we are acquainted were one of three 
weeks by Halsewood, 1 and another successful one of our own, and one of four 
weeks by Maunder. The sac always requires opening, since the neck itself 
forms the constricting part. Sometimes in an hour-glass sac the constriction 
may be in the scrotum. 

The treatment of hernia in children resolves itself into three questions- 
first, the removal of all causes tending to produce rupture, such as cough, 
phimosis, &c. ; secondly, treatment by apparatus : and lastly, operations. 

Ruptures in children sometimes get well of themselves without treatment, 
or simply by keeping the child lying down and avoiding disturbance of its 

1 Lancet, Dec. 1884. 



I 50 Diseases of the Digestive System 

temper and bowels. In other instances circumcision will prevent further 
descent of hernia by removing the source of straining. 

Failing these means, the wisest plan is at once to provide a well-fitting 
truss, a matter which should be seen to by the surgeon himself, and not left 
to an instrument maker. The truss must be worn night and day without any 
intermission, never being removed on any account for washing or any other 
purpose except to put another on ; this is necessary, because the truss is in 
children used to cure rupture, and not merely to palliate it as in adults. When 
it is absolutely necessary to change a truss, the new one must be got ready, 
the finger slipped beneath the old one to keep pressure upon the canal and 
then the truss changed, the child being kept on its back and soothed to pre- 
vent crying. During the treatment the skin must be carefully watched and 
kept dry and unirritated by the free use of boric acid powder; this can be 
dusted beneath the truss without removing it. A little judicious packing with 
absorbent wool will serve to take pressure off any tender part. Almost any 
hernia during the first year of life that can be kept up without once coming 
down for three months will be permanently cured ; after the first year a 
longer time is required. 

The ordinary flat- pad trusses do very well if the parents can afford to fre- 
quently renew them, but they get stiff and hard, and the springs soon rust 
and rot with the frequent soakage of urine, so that they have to be frequently 
changed, and a duplicate should always be at hand in case of sudden giving 
way. One descent of a hernia undoes all the preceding treatment ; this is the 
cardinal rule to impress upon the mother or nurse. The inflatable and the 
glycerine pad rubber trusses we have found useful and satisfactory when 
carefully managed, and they are not affected by urine nearly so rapidly as the 
common truss, but they require careful inspection from the first, as they are 
often imperfectly made, and flaws or tears are soon fatal to them. The hard 
rubber truss is sometimes spoken well of; we have not tried it. If from 
bad management a sore is produced by truss pressure, careful padding will 
often avoid the necessity of leaving off the truss ; but with proper attention 
and care that the truss spring is not too strong, it seldom occurs. 

Hydrocele and orchitis we have more than once seen as the result of 
wearing a truss ; in such cases we may be sure that the spring is too strong 
and a different truss must be applied. Spica bandages, wool trusses &c. 
are inefficient substitutes for a good truss. The pad of the truss should be 
flat and not convex, and peaked trusses are never required ; the object is to 
prevent the hernia from entering the canal, not merely to cover up the 
rupture. 

When a fair trial has been given to trusses, different ones being, if 
necessary, employed, and all souices of irritation have been removed and 
still the rupture cannot be kept up, an operation for its permanent cure 
should be performed ; it is of course required in only a small percentage of 
cases. 

Of all the various plans, the one we think simplest and as good as any, 
and the only one we shall describe, consists in making a free incision over 
the canal and upper part of the scrotum, cutting down to the sac, reducing the 
hernia, closing the neck of the sac, and passing silver wire or silk sutures 
through the walls of the canal and twisting them up. To do this the sac 



Hernia — Prolapsus Recti 151 

must be opened and the finger passed into the abdomen to make sure that 
the canal is clear and to guide the needle. The needle, which must be in a 
handle, is passed through one side of the canal, and guided by the finger is 
brought out at the ring ; it is threaded with wire and withdrawn, then un- 
threaded and passed through the other side, then threaded with the other 
end of the same wire and again withdrawn ; two or three sutures are passed 
in this way till it is felt that there are enough to close the canal, the wires 
are then twisted up, cut short and their ends well turned down into the 
tissues. One edge of the sac close up to the wires is then picked up and 
threaded upon the needle, and successive portions of the surface of the sac 
are pinched up and transfixed (like threading them upon a skewer) until the 
other edge is reached ; the needle is then threaded with catgut or silk and 
withdrawn, leaving the ligature, which when tied puckers up the sac into 
closely applied folds which soon adhere, and the sac is thoroughly obliterated ; 
by this means all trouble and disturbance in separating the sac from the cord 
is avoided, and the closure is quite firm and complete. Sometimes we liga- 
ture the sac before closing the canal ; this is not quite so easy, and it is not 
a matter of importance. The silver wires are left in permanently unless they 
set up irritation, when they are removed as soon as they are loose, but this 
seldom happens. The wound should be closed, and will heal by primary 
union. Of late we have used silk in preference to wire, but it requires care- 
ful preparation ; if not thoroughly sterilised, a troublesome sinus is likely to 
form, and the suture finally comes away. We prefer to select the particular 
mode of operation most suited to the case, rather than to confine ourselves 
to any one method exclusively. There is sometimes a great deal of swelling 
after the operation, but this gradually subsides and should be looked upon 
as a good sign of firm consolidation. For the methods of managing com- 
plications of the operation we must refer to the ordinary text-books, for 
undescended testis to the chapter on that subject. An omental sac may 
be met with ; we have seen a very perfect instance. The management of 
such cases and of adhesions differs in no way in the child from that of 
similar conditions in the adult. It is better not to allow a truss to be worn 
after the operation unless there is some special reason for it. 

The operation is not free from risk and not always successful ; we have 
had one death from peritonitis coming on some time after the operation, and 
have had to operate more than once in several cases. In the fatal case the 
canal was perfectly closed and the peritoneal surface almost undimpled. 

Femoral hernia in children is very rare, we have never seen a case ; one 
recorded by Sabourin in a premature female infant was readily cured by a 
truss. E. Owen saw one in a boy of 10 years out of 748 cases of femoral 
hernia l Diaphragmatic hernia is occasionally met with. 

Prolapsus Recti. — Slight degrees of prolapse of the rectum arc common 
in children and are often only transitory, occurring perhaps once or ;w ice and 
not again ; the more severe forms are much rarer. 

Prolapse of the rectum consists in protrusion oi more or less of the 
rectal wall through the anus. The slight and most common form is simply 
a pushing out of a ring of mucous membrane, which is readily reducible and 

1 Lancet, June 6, t88 1 



152 Diseases of the Digestive System 

often only comes down when the child strains. In other cases the whole of 
the rectal coats from mucous membrane to peritoneum may be protruded. 

The first variety of prolapse is usually about half an inch long and appears 
as a red mucous ring with radiating folds diverging from the central orifice ; 
the mucous and cutaneous surfaces shade off into one another at the margin of 
the protrusion. The second form is larger, reaching from one to two inches 
in length, and is often conical in shape, its base being at the anus ; the folds 
are not radial but annular, running round the prolapsed part ; the orifice is 
central, and on passing the finger into it, it is evident that the whole thickness 
of the bowel, and not merely mucous membrane, is involved in the prolapse. 
Sometimes this form of protrusion reaches much larger dimensions, even six 
inches in length, and in such cases necessarily a large pouch of peritoneum 
is carried down, and this is more extensive on the anterior than the posterior 
aspect of the bowel. In one case that we examined post mortem there was 
a definite diverticular pouch with a sharp lunated edge projecting from the 
recto-vesical hollow down the anterior wall of the rectum ; it seemed to 
us probable that the presence of a coil of bowel in this pouch would have 
much to do with keeping down the prolapse. 1 Not only small intestine but 
the ovaries even may be found in this peritoneal pouch, which then becomes 
the sac of a rectal hernia ; the characteristic gurgling or the presence of a 
solid body felt on manipulating the wall of the protrusion may give a clue to 
the extent of the disease. Rectal hernia sometimes comes down behind 
the bowel, or may even protrude through a gap in the muscular coats. 
(Kelsey.) This variety of prolapse is sometimes curved as a result of 
traction by the mesocolic fold of peritoneum or the attachment of the rectum 
to the vagina. (Van Buren.) In it also the mucous and cutaneous surfaces 
shade off into one another, though the transverse folds of mucous membrane 
on the surface of the prolapse may somewhat obscure the line of junction. 

A so-called third form of prolapsus recti, where the upper part of the 
rectum or the sigmoid flexure is invaginated into the bowel below and pro- 
trudes from the anus, is recognised by its size and by the presence of a sulcus 
between the prolapse and the anal margin. This condition, however, is more 
naturally considered as an intussusception than as a prolapse. 

The mucous surface of the protruded gut maybe nearly natural, but more 
often is excoriated and coated over with a thick slimy mucus ; it sometimes 
becomes congested and may even slough from irritation or constriction by 
the sphincter, though in most cases the anus is so lax and patulous that the 
existence of a sphincter at all is hardly felt by a finger passed within the 
opening. Bleeding to small amounts often occurs, and there is much mucous 
discharge. 

The motions come away freely, but the irritation and discharge weaken 
the child, and he loses flesh and health. In most cases the prolapse is re- 
ducible with more or less difficulty, but often it returns immediately pressure 
is taken off ; in others it remains up until the child strains from any cause and 
then redescends ; in others again the protrusion after a time becomes irre- 
ducible from matting together of the parts and from congestion. 

1 The specimen from this case is in the Owens College Museum ; this definite pouching; 
is, so far as we know, undescribed hitherto. 



Prolapsus Recti I 5 3 

Where a rectal hernia exists it is subject to all the conditions of an 
ordinary inguinal hernia, i.e. it may be reducible or strangulated, &c.' Occa- 
sionally the prolapse sloughs and faecal fistula results, or the wall may burst 
in attempts at reduction. 

The causes of prolapsus recti are many, though it is obvious that there 
must be some weakness of the sphincter and levator ani or relaxation of the 
rectal walls in these cases, or prolapse would be much more frequent than it is. 
Any condition that produces violent and constant straining may bring on 
prolapse in a child predisposed to it. The child is generally miserable and 
weakly when seen, but this is no doubt partly the result of the irritation. 
Phimosis, contracted meatus urinarius, stone in the bladder, cystitis, con- 
stipation, diarrhoea, worms, polypus recti, violent coughing all may cause 
prolapse. Boeckel believes stricture of the rectum to be a cause, and in 
one case Ave found a tight annular stricture of the rectum about one inch 
from the anus ; this only admitted the tip of the index finger in a child of 
about three years old : the stricture apparently formed the apex of the 
prolapse and may possibly have been a result rather than a cause of the 
protrusion. 

The diagnosis of prolapsus recti is easy where the protrusion is large ; the 
only doubtful point is what extent of rectal wall is included in it. If small 
it can only be mistaken for piles or polypus ; the former are exceedingly rare 
in children and never form a complete ring, the latter is of course a single 
isolated, usually pedunculated swelling ; a mistake can only occur from lack 
of examination. Kelsey lays it down that any prolapse over i\ inches in 
length contains peritoneum, while the presence of a sulcus serves to dis- 
tinguish between the second form and the rectal intussusception. The 
direction of the folds and the size distinguish between the first and second 
varieties. 

The treatment of prolapse consists first in removing the cause of strain- 
ing, next the child should be kept rigidly lying down in bed ; the protrusion 
must be reduced each time it comes down, and if it constantly recurs an 
attempt should be made to keep it up by a pad and T-bandage, or by 
strapping the buttocks together with a broad piece of plaster. The bowels 
should be kept easily open so as to avoid straining, and it is sometimes 
useful to support the sides of the anus during defalcation by pressure or by 
drawing the skin tightly to one side ; as advised by Van Buren, the 
motions should be passed into a napkin without the child being allowed 
to sit up. 

Enemata of cold water or astringents, tannin, quassia (2-4 oz. of the 
infusion), oak bark, sulphate of iron, &c, will do good in many cases, and it 
is only the more severe forms that are not cured by bed and the means 
above described ; indeed, simple confinement to bed cures the majority o( 
these children. Should the prolapse be irreducible, an anaesthetic should 
be given ; if this fails and there are no urgent symptoms, a warm fomentation 
and putting the child, if old enough, upon his hands and knees with the pelvis 
raised, will sometimes succeed. 

If sloughing occurs the prolapse may be protected from irritation, and 
dusted over with boracic or salicylic acid, and kept clean. The sloughing 
1 Vide Kelsey, in an elaborate paper in . Irchivei ■ .. .-. 1885. 



154 Diseases of the Digestive System 

will very likely cure the prolapse, but it may be at the expense of causing 
a stricture, and this, if it is at the apex of a long prolapse, will be high up 
in the rectum when the protrusion is reduced. 

Failing milder measures, the actual cautery should be employed, four or 
five narrow lines being drawn in the long axis of the gut from skin margin 
to near the apex. 

Paquelin's cautery is the most useful instrument, and is better than 
nitric acid or nitrate of silver. Only the mucous membrane of the prolapse 
should be burnt through, while at the skin margin the cautery should lay 
bare the sphincter ; sufficient irritation must be produced to procure adhe- 
sions between the mucous and muscular coats. Bryant advises the applica- 
tion of nitrate of silver over the whole surface. After the application the 
bowel should be reduced and a pad applied. Another useful plan is to 
excise wedge-shaped strips from the margins of the anus, including a little 
of the mucous membrane, the base of the wedge being at the anus ; the 
edges of the wounds are then brought together, and the resulting contraction 
supports the bowel. We have found this successful in a very severe case. 
In severe and irreducible cases the prolapse has been clamped and removed, 
but this should only be done as a last resource and with the full knowledge 
that in a large prolapse the peritoneum will probably be opened, and the 
utmost care must be taken to reduce any rectal hernia that may exist. If the 
peritoneum is wounded it must be carefully closed with catgut sutures. This 
operation is rarely justifiable ; we have once done it but unsuccessfully ; it is 
not to be confounded with the method of treating prolapse by removal of strips 
of mucous membrane in the long axis of the gut by means of the clamp, a 
method sometimes employed. 1 

The bowels should be open two days after operation, as delay makes the 
first action very painful. 

Fistula in Ano is an uncommon condition in children, though we have 
several times met with it. As in adults, it is apt to be associated with 
tuberculosis. As pointed out by Mr. Holmes, most of the fistulas are blind 
external ones ; this is also our experience. There is nothing peculiar in 
either the pathology or treatment, Avhich is the same in children as in adults. 

We have, however, recently introduced the plan of dividing the sphincter 
ani subcutaneously close to its attachment to the tip of the coccyx, and then 
scraping out the fistula. This is a less severe way of dealing with fistulas 
than the ordinary plan, and is probably sufficient for all cases likely to be 
met with in children. 

Piles in children are usually described as unknown, or almost so, and 
their occurrence is no doubt very rare ; we have, however, seen two cases of 
external piles, and Ogston, jun., has recorded a case in a child 3 days old. 
In another instance a child was brought to us for bleeding from the bowel, 
and on examination a condition indistinguishable from that of well-developed 
intero-external piles was found ; this had been giving trouble since the child 
was about a year and a half old, but the affection was probably congenital. 
Light was thrown upon the case by the presence of a large partially 

1 Dr. Cullingworth related at the Pathological Society of Manchester, December 1887, 
a successful case of complete excision of a large prolapse in a young lady in which the 
peritoneum was opened. 



Condylomata — Rectal Polypus 155 

degenerated nsevus on the buttock, quite distinct, and at a distance from 
the anus, and probably the case was really one of nawus of the anus. The 
disease was readily cured by applying ligatures just as for piles. There was 
no nasvoid tissue higher up, though this is occasionally met with. Ligature 
or the actual cautery is the best treatment. Howard Marsh and Barker 
have recorded instances : in one the patient, an adult, ultimately died of 
haemorrhage. 

Condylomata frequently occur in children about the anus or its neigh- 
bourhood as flat, sessile, pink or pinkish-white elevations, or sometimes as 
large irregular masses. They are usually a manifestation of congenital syphi- 
lis, but sometimes, we believe, simply the result of dirt and irritation. When 
syphilitic the local treatment is, of course, subordinate to the general measures, 
but dusting over with calomel or the application of black wash usually speedily 
cures them. Sometimes, especially if non-syphilitic, they are more obstinate, 
and may require to be scraped away or treated with the actual cautery, nitrate 
of silver, or chromic acid. 

Polypus of the Rectum is one of the diseases which, though not abso- 
lutely peculiar to children, are by far most commonly found in them. Most 
cases of rectal bleeding in children, apart from that due to mere tenesmus 
and diarrhoea, are due to polypus ; hence careful search should be made for 
a tumour in all cases where unaltered blood escapes from the bowel. 

Rectal polypi are usually pedunculated rounded bodies about the size of a 
hazel nut ; they are composed of myxo-fibromatous or soft fibro-cellular tissue, 
•or in some cases are adenomata ; in the former form the surface is smooth, 
though sometimes superficially ulcerated or excoriated, and the pedicle is 
often long and thin, though the growth in its early stages may be sessile. 
Adenomata are granular or warty in appearance. The anterior wall of the 
rectum about an inch from the anus is the usual seat of these growths ; some- 
times, however, they are attached higher up in the bowel, and may be even 
beyond reach of the finger. 

Polypi, besides the loss of blocd, give rise to irritation and tenesmus, 
together with a mucous discharge from the gut, and frequently to prolapse. 
The growth itself is often protruded from the anus during straining, and is 
sometimes mistaken for prolapse or piles ; examination, however, readily 
enables a diagnosis to be made, as the polypus is quite separate from the 
general mucous surface. The pedunculated form is best treated by simple 
twisting off, or a ligature may be applied to the pedicle, which is then snipped 
through with scissors ; to do this conveniently the child should be anaesthe- 
tised, and the rectum well dilated and a speculum used ; often during an 
examination the pedicle is torn through and the polypus comes away without 
further trouble, and occasionally the mass is detached during defalcation and 
passes with the motion. The sessile form maybe ligatured or snipped ot't 
and its base cauterised. Recurrence of the growth is improbable. 

We have met with rectal polypus in two members oi one family, and 
Cripps relates similar cases. 

Occasionally the whole mucous surface of the lower bowel is the scat o( 
warty adenomatous growths, as in a remarkable case recorded by our 
colleague Mr. Whitehead. Dermoid cysts have also boon found. 

Small superficial ulcers and fissures about the anus arc common in dirty 



156 Diseases of the Digestive System 

and in syphilitic children, but they are more common at a little distance from 
the orifice than actually at the anus. They give rise to pruritus, but seldom 
to the severe symptoms seen in adults ; sometimes there is reflex irritation 
of the urinary organs, frequent micturition, &e. In the non-syphilitic cases, 
cleanliness, the destruction of worms or other irritants, and the application of 
nitrate of silver are usually sufficient. Menthol has been recommended for 
the pruritus. Tuberculous ulcers may be met with. Ischio-rectal abscess is 
not very uncommon, and should be opened early; it is probably better to 
divide the external sphincter at the time to avoid the risk of tedious healing 
or the formation of a fistula. 

Rectal ulcers are due to either follicular inflammation, in which the 
rectum is involved in common with the rest of the lower gut, or to rectal 
catarrh or the presence of a polypus. The symptoms are seldom marked, 
and the condition is consequently not often seen ; vide also PROLAPSE and 
Dysentery. 

Removal of irritation and improvement of the general condition of the 
intestinal mucous membrane are the only treatment required. 



157 



CHAPTER IX 

DISEASES OF THE DIGESTIVE SYSTEM — {continued) 

Malformations and Deformities of the Digestive System 

Hare-lip. — The upper lip is developed from the fronto-nasal process and 
the maxillary processes which in the normal course of development fuse in 
front of the mandibular fissure. Should this fusion fail to take place on 




Fig. 18.— Shows the lines of union of the face, and indicates the origin of the chief malforma- 
tions, af, ak', situations of congenital auricular fistulse. [., II., III.. IV.. indicate the 
external orifices of branchial fistula-. I. is the external auditory meatus ; ok. the orbital 
fissure; mf, the mandibular fissure: 1111', the lines of lateral hare-lip: cf, cf', mark the 
situations of congenital cervical fistulae, (From Bland Sutton, Lancet, Feb. r, 188S.) 

either or both sides, a single or double hare-lip respectively results. If 
the inward growth of the palatine processes which should take place 10 
separate the nasal and buccal cavities tails, cleft palate occurs. 



5 



Diseases of the Digestive System 



The praemaxillae are formed from the globular processes forming the 
angles of the fronto-nasal process; hence, should the lateral process not fuse 
with the globular, a cleft between the praemaxilla and the maxilla will 
result on that side, while, if there is suppression of the two globular pro- 
cesses and septum, median hare-lip follows ; this, though exceedingly rare in 
man, is met with more or less constantly in some mammals in which the 
globular processes fail to unite with one another. 1 

As to the actual causes of such arrest of development much controversy 
exists. It is commonly asserted that frights and shocks of various kinds, as 
well as strong maternal impressions of other sorts occurring about the 
time of the development of these parts, may determine the arrest of growth 
which results in such malformations. Although many instances have been 
brought forward to show a causal relation between the two facts, it is not 
clearly established that anything more than a coincidence really exists. 

It is, however, certain that in many cases there is an hereditary tendency 
to such defects, and it is also certain that they are often associated with other 

congenital malformations. It is asserted 
that the hereditary tendency is commonly 
transmitted on the father's side. 

Various degrees of hare-lip are found ; 
Mr. Lucas believes that congenital absence 
of an upper lateral incisor is sometimes 
the forerunner of hare-lip and cleft palate 
in a later generation ; in some instances 
there is merely a deficiency of the mus- 
cular fibres of the orbicularis, so that 
although the lip is not actually fissured 
there is a furrow from the absence of 
muscle and the consequent thinning of the 
lip which at the affected part consists only 
of skin and mucous membrane, often some- 
what imperfect in structure, together with 
an intervening layer of connective tissue. 

In other cases there is a shallow notch 
in the prolabium or at the anterior nasal 
orifice, the parts being otherwise well 
formed. Between these conditions and 
the most severe forms of hare-lip all degrees of deformity may exist (figs. 
19 and 20). 

As the superficial structures are developed more or less independently of 
the bony framework of the face, hare-lip may occur without any cleft of the 
palate, and without any separation of the praemaxilla from the maxilla. Most 
commonly, however, if the hare-lip is complete, i.e. if it extends into the 
nostril on one or both sides, there is also deformity of the bones, either non- 
union of the praemaxilla or single or double cleft palate. Thus there may 
be a mere notch in the line of the gum, a cleft through the alveolar margin 
on one side, a cleft running backwards, on one side of the nasal septum 
through the hard and soft palates, or a double cleft isolating the praemaxilla 
1 Vide Bland Sutton, Lancet, February 18, 1888. 




Fig. 19. — A simple case of Double incom- 
plete Hare-lip. This is much rarer than 
the complete variety. 



Hare-lip — Cleft Palate 



159 



from the maxillas and leaving it protruding from the end of the nasal septum 
while the two halves of the hard and soft palate are completely separated and 
the nasal septum is seen in the middle line as a prominent ridge not attached 
to either side of the palate — complete or double-cleft palate— the septum is 
often seen to taper off and end as a ridge upon the upper wall of the pharynx. 
It is usually said that cleft palate is always single, but the term may well be 
limited to those cases where the septum is attached to one palate process 
only. In other instances the failure of union may occur only in the soft 
palate, more often in the soft with just the posterior edge of the hard palate, 
or in slighter degrees of the deformity still the uvula alone may be bifid, or 
the palate perforated. In some recorded cases the uvula has been absent. 

Two other conditions associated with hare-lip and cleft palate respectively 
are of extreme importance as regards successful operation ; the one is the 
flat, wide, distorted ala of the nose found in complete hare-lip ; the other is 
the pitch of the palate arch, which may be either wide and flat or very high 
and narrow ; the latter 
condition is said to be 
often associated with men- 
tal deficiency. 

Sometimes the prse- 
maxilla carries the four 
incisor teeth, and these 
are therefore implanted in 
the projecting mass in 
cases of complete double 
hare-lip. In some in- 
stances, however, one in- 
cisor tooth is attached to 
the maxilla, most com- 
monly the outer tooth is 
suppressed altogether, its 
sac having apparently 
been lost in the cleft. 

Rotation of PrccmaxiUa. — Very frequently there is some rotation of 
the praemaxilla upon a vertical axis, especially in unilateral cleft ; in such 
cases the teeth are also rotated and may be so directed that the outer border, 
or in some instances the cutting edge, looks directly forwards. This position 
of the teeth requires to be remedied after their complete eruption. As. how- 
ever, hare-lip is now usually operated upon before the teeth are cut, their 
exact position is in such cases of little importance at the time. 

Feeble Vitality. — The deformity of simple hare-lip unaccompanied by 
malformation of the palate is important almost solely on account oi the 
disfigurement, though it must be borne in mind that many o\ these children 
have other deformities or arc weakly, and, though without any actual malforma- 
tion, do not seem to have sufficient vitality to make it possible to lear them. 

When, however, the failure of the union affects the palate as well as the lip. 
other ill results follow ; the child is unable to sink horn inability to produce 
a vacuum in the mouth ; its nasal passages and pharynx are exposed to the 
air and become affected with chronic catarrh, its tongue is dry and the air 




-Severe Double Hare-lip. Showim 
praemaxilla. 



the projecting 



160 Diseases of the Digestive System 

entering its lungs is imperfectly warmed. Even when fed with a spoon the 
food often regurgitates through the nose. Hence to the already weakly con- 
dition of the child are added the dangers of insufficient nutrition and catarrh 
of the respiratory tract. It is not, therefore, to be wondered at that only a 
small proportion of children so affected survive ; should they do so, they are 
subject to the further drawback of imperfect and indistinct speech. It is 
alleged that many of these children die from starvation, which might be 
prevented by operation : we do not think this is true ; we believe they would 
die in any case from simple lack of vitality. 

In those cases where the child is unable to suck, it should be fed in an 
upright posture, when the milk is less likely to regurgitate through the nose, 
or one of the special obturator teats devised by Mr. Mason aud others em- 
ployed ; probably the best of these is Oakley Coles' rubber teat. 

The treatment of hare-lip is necessarily purely operative ; several impor- 
tant questions have, however, to be considered in each individual case. First, 
it is clearly of no use to operate on an infant that is incapable of living from 
the presence of some other deformity incompatible with life, nor in cases 
where the general health of the child is feeble and it is losing weight, since 
union of the wound would not take place. Xo operation then should be 
done unless the child is in perfect health, and the time of actually cutting a 
tooth should be avoided. 

Age for operation. — Next comes the question of the best age for opera- 
tion. On the one hand it must be borne in mind that there is a certain 
amount of risk attending the necessary loss of blood and the shock in a very 
young infant, and on the other hand that, if the deformity is severe, the effect 
of closing the cleft in the lip as regards moulding the subjacent parts into 
their natural shape will be greater the younger the child and the softer the 
tissues. As has been well shown by Dr. Rawdon, of Liverpool, and others, 
a most remarkable modelling process in the outline of the upper jaw takes 
place after closure of a hare-lip, and more than this, the width of the cleft in 
a divided palate is much reduced after a time by uniting the lip. 

Increased facility in feeding and the removal of a hideous deformity are 
•other reasons for early interference, while experience shows that early opera- 
tion is not attended with a specially high rate of mortality. Many infants 
die shortly after the operation for hare-lip, but in most of these death is due 
to malnutrition, not to the operation. 

The common practice now is to operate at any time after the first three 
weeks of life in the less severe cases and a month or two later in the more 
serious deformities, double hare-lip being dealt with later still ; operations 
are, however, often successfully done within the first few days of life. Our 
own preference is not to operate before a month in single hare-lip, nor before 
six months in severe deformity. 

Operation. — It is, in our opinion, much better in all cases to give chloro- 
form for the operation. The coronary arteries should then be controlled by 
bulldog forceps or finger pressure, and the lip very freely detached from the 
maxilla, the dissection being carried far outwards along the jaw, upwards 
nearly to the lower margin of the orbit, and inwards and upwards so as to 
freely detach the ala nasi from the subjacent bone. 

The extent of the separation will, of course, depend upon the severity of 



Hare-lip 1 6 1 

the case ; but, as a rule, failure is more often due to insufficient separation 
than to any other single cause. 

The bleeding during this part of the operation is often free, but is easily 
controlled by pressure, and stops immediately after the stitches are put in ; 
for this reason we sometimes pare the edges of the cleft before freeing the 
lip, though if the paring is done last it is easier to adjust the edges exactly. 
It is very important to slice away the sides of the cleft freely, and not merely 
to scrape them or take away a thin shaving ; too little is much more often 
taken away than too much. 

In adjusting the edges of the wound, the chief points to attend to are that 
the prolabial margin on one side exactly corresponds with that on the other ; 
secondly, that the highest suture is well within the nostril, so as to prevent a 
gap at the upper margin, and to remedy the tendency to flattening of the 
nostril ; thirdly, to insert a suture on the inner and under (mucous) surface 
of the lip ; this more than anything else prevents the appearance of an un- 
sightly notch at the lower end of the line of union. The main sutures should 
be made to include the whole thickness of the lip except the mucous mem- 
brane ; the intermediate ones may be only superficial. 

Silver wire sutures, usually about three in number, with intervening horse- 
hair stitches, will be found very successful, and are, we think, on the whole, 
the best. 

Hare-lip pins are hardly ever necessary, and should not be used if it is 
possible to avoid it. We have not used them for years. If the lip is freely 
separated from the upper jaw, there will be no tension. We used sometimes 
to put pins in temporarily to keep the parts in apposition while the rest of the 
stitches are being inserted, and then remove them at the end of the opera- 
tion. If the pins are left in, it should be for not longer than forty-eight hours ; 
the rest of the stitches may be taken out a day or so later, according to the 
amount of irritation set up and the condition of the child. Where the power of 
repair is feeble, the sutures should be left in longer. Some surgeons prefer silk 
or gut sutures. The first stitch, if pins are not used, should be put in oppo- 
site the prolabial margin ; this answers the double purpose of controlling the 
coronary arteries and of fixing the level of adjustment of the two sides. If 
forceps have been used for controlling the bleeding, they should be removed 
just before putting in the stitches. 

Some surgeons apply a strip of strapping over the lip after the operation, or 
use a Hainsby's truss ; neither is necessary. We prefer to dust the wound over 
with boric powder and leave it exposed. The strapping is objectionable in 
that it tends to collect blood and mucous discharge from the nostril, and so to 
irritate the wound. It is, however, sometimes wise to put plaster on for forty- 
eight hours after removing the sutures until the union is quite firm, and it is a 
good plan to lay a narrow strip of lint over the line of union beneath the plaster. 

If the child has not been weaned before the operation, it should be 
allowed to suck as soon as it recovers from the chloroform : in such case 
care must be taken to prevent injury to the mother's breast from the wire 
sutures. In most cases, however, the child has been bottle or spoon i'ed. 

In any case the hands must be carefully secured by bandaging them to 
the chest with a flannel bandage or by some similar means, And watch kept 
that no injury is done to the lip. 

M 



1 62 Diseases of the Digestive System 

The principal methods of opc?'ati?ig for single hare-lip are as follows : 
each case must be managed according to its special needs, no one method 
answering in all cases : 

i. The edges of the fissure are simply pared by a straight incision and 
brought together. This, though answering well in some cases, is apt to leave 
a notch at the prolabial margin unless there is abundance of material to work 
with. By making the line of incision slightly curved, with the concavity 
to wards the cleft, the notching may often be avoided (fig. 21, e,f). 

2. The single flap method shown in fig. 21 (c, d) is often useful. 

3. Malgaigne's operation of turning down two opposed flaps may be em- 
ployed ; it is chiefly useful for cases where a notch remains after previous 
operation (<z, b). 

4. Perhaps the most generally applicable methods are those shown in 
fig. 21 {c-d,e-fg). 





f L 9 

Fig. 2i. — Diagrams slightly altered from Lane ('Operative Surgery") to show the modes of 
refreshing and uniting the edges in single hare-lip. In a, b, the angular incision allows two 
flaps to be turned downwards. In c, d, a single flap from the left side is fixed to the opposite 
side. In e.f, the ed?es are pared, making the lines of incision strongly concave inwards. 
g shows Golding-Bird"s 'rectangular operation' (vide Brit. Med. Journ. October 1890). 

5. The more complicated operations of Giraldes and Collis are seldom 
employed, but it is occasionally very useful to carry the incision round the 
ala of the nose in severe cases ; by this means the depth of the lip can be 
greatly increased ; this plan was, we believe, first employed by Dr. Rawdon, 
of Liverpool. Many other methods are described. Owens is very good. 

In double hare-lip two special difficulties have to be met, the management 
of the praelabium and of the praemaxilla. The praelabium may be — 

1. Pared at its sides and free extremity so as to make a semicircular or 
tongue-shaped flap which is fitted between the upper parts of the two lateral 
flaps, these having been previously pared. 

2. If long enough, the praelabium may be brought down to make the 
central part of the lip, being pared only at its sides, and the lateral flaps are 
then fitted to it instead of to each other. 

3. The central flap may be removed altogether, and the two sides brought 
together throughout their whole length. 

4. The praelabium, having been dissected away from the praemaxilla, may 



Cleft Palate 163 

be doubled upon its base and turned up to form a columna for the no 
The first and second of these plans are the most generally useful. 

The praemaxilla in some cases may be pushed gradually backwards by 
constant pressure with a pad before the hare-lip is operated on, or it may be 
forcibly pushed back at once ; this is open to the objection pointed out by 
F. Mason, that the wedging back of the prsemaxilla may tend to keep open 
the cleft in the palate. Removal of a wedge-shaped piece from the septum 
nasi or of lateral pieces from the prsemaxilla is a plan sometimes adopted. 
The method we prefer where the prsemaxilla cannot be covered is to shell 
out the bone, leaving the muco-periosteum to preserve the outline of the lip, 
and then bring the lip together ; ' this, we think, is certainly better than entire 
removal of the praemaxilla, which produces flattening of the lip. Where the 
praemaxilla is turned upon a vertical axis so that one edge looks forwards it 
may be forcibly rotated into position, but if the lip can be united over the 
projection the prominence will, as already pointed out, soon diminish. 

Any notch left at the free margin of the lip or at the nostril can usually 
be closed by a subsequent operation. Should primary union fail throughout, 
an attempt should be made at once to procure secondary adhesion by either 
putting in fresh sutures, or, if the tissues are too soft and inflamed to hold 
them, by applying strapping to bring the sides together. If the child's 
health is good, this will probably succeed ; failure is, however, often due to 
malnutrition : in such cases union cannot be expected to occur, and a second 
attempt should be put off until the health is improved. It is wiser not to 
operate too soon a second time ; many cases that look unsatisfactory after 
operation improve much in time. 

The particular mode of operating must be selected for each individual 
case, looking especially to the size of the central portion of the lip in double 
hare-lip and to the inequality of the two sides in the single deformity. 

Cleft Palate. — The varieties of cleft palate have already been mentioned. 
The severer forms are commonly associated with double hare-lip — indeed, it 
is said to be very rare for double hare-lip to occur without cleft palate, and no 
doubt this is true in the complete forms of hare-lip. 

Here a brief account of the modes of treating the deformity can alone be 
given. 

For choice the operation should be performed between the fourth and 
sixth years, but in the less severe cases it may be done as early as the third 
year ; before this it is not wise to attempt it, 9 unless in exceptional circum- 
stances, since the risk both of failure of the operation and of the child's 
life is much greater, though some surgeons advocate operation in the second 
year. As in all plastic operations, care must be taken that the child is in 
good health. The other general rules to be observed are : the edges o\ the 
cleft must be freely pared, all tension must be carefully avoided, the muco- 
periosteum must be thoroughly loosened at the junction of the hard and soft 
palates in cases of cleft of the velum alone, no hard food must be given till 
union is complete, and if the operation is only partially successful or fails 
altogether, another attempt should be made at the end o( three months. 

1 This method was Introduced by Sir W. Fergusson. 

- Mr. Clutton has operated successfully in two Favourable cases of cleft of the soft 

palate at [2 months old. Lancet, June 6, 1887. 



164 Diseases of the Digestive System 

Staphylorap/iy, or the operation for closure of a cleft of the soft palate, 
consists in freely paring the edges of the cleft throughout, then a sufficient 
number of sutures are passed, and next the attachment of the soft palate to 
the hard is carefully loosened, and finally, the palate muscles having been 
divided to relieve tension, the sutures are tightened up. The exact mode of 
operating that we prefer is as follows. The child is anaesthetised, a pillow- 
is placed beneath the shoulders, and the head allowed to fall right back so 
that the roof of the pharynx is almost horizontal ; in this position light 
enters the mouth well, and the blood and saliva collect in a pool in the 
pharynx instead of irritating the larynx. A gag is then inserted, the whole 
of the cleft carefully pared, and then from four to seven wire sutures are put 
in in the following way : a slightly curved needle in a handle is passed 
through the edge on one side into the cleft, it is then threaded with wire and 
withdrawn, the wire is disengaged, the needle passed similarly through the 
other side and threaded with the end already passed ; this is then drawn 
through the second side by removing the needle, bringing the wire across 
the gap with the two ends projecting on the oral surface. 1 For the uvula we 
often use horsehair sutures. When all the sutures are passed an incision is 
made through the muco-periosteum of the hard palate down to the bone on 
each side of the front of the cleft and well away from it, the muco-periosteum 
is then carefully detached from the bone all round the anterior extremity of 
the cleft so that the soft parts are quite free and loose. Next, holding all 
the sutures together in the left hand, the palate knife is carried backwards 
and outwards from the incision already made until the levator and tensor 
palati are freely divided and the velum is quite lax. Sometimes it is well 
to divide the palato-glossus and pharyngeus by snipping through the pillars 
of the fauces. If there is no tension it is a good plan to make the relaxation 
incisions after twisting up the wires. A minute or two is then given up to firm 
pressure with a sponge upon the palate, so that all bleeding may be stopped. 
Finally, the wires are twisted up : we usually begin with the middle wires, 
as they bear tension best. The ends are then cut short, the cleft inspected to 
see that the lips are accurately adjusted, and that there is no tension, and the 
gag is then removed. 

Various modifications of the operation are of course well known, and will 
be found described in the general text-books. 

During the operation it is important to avoid the use of sponges as long- 
as possible, since mopping out the pharynx much increases the amount of 
secretion poured out. 

The after treatment. — The hands must be carefully secured to avoid 
injury to the palate, and no solid food should be given for a week. Many 
surgeons give nothing by mouth at all for forty-eight hours, and feed the 
patient by enemata. Others allow milk from the first, and sops after two or 
three days ; others, again, allow soft solids from the first ; probably it is better 
to restrict the diet to milk for two or three days and then allow soup and 
sops till the end of the week ; after this the ordinary diet may be gradually 
resumed, avoiding of course any hard or irritating material. The stitches 
we usually leave to take care of themselves, and nothing more is seen 

1 For knowledge of this most simple plan we are indebted to our colleague, Mr. 
Hardie. 



Cleft Palate 165 

of them ; the child probably spits them out. If, however, they are setting- up 
irritation, or if after a few weeks they have not come away, they should be 
removed. Any little granulating- point or small perforation left at the anterior 
extremity of the cleft will usually heal up of itself; if it does not do so the 
application of nitrate of silver will sometimes succeed, or in other cases a 
second little operation may be required. 

Only one mode of performing the operation of Uranoplasty^ or closure 
of a cleft of the hard palate, will be described here ; in our experience it is 
much more successful than the other plans, and if it fails there is less difficulty 
in a second operation than after the so-called osteoplastic method. 

Operation by miico-periosieal flaps consists in paring the edges of the 
cleft throughout, then an incision is made midway between the alveolar margin 
of the palate and the cleft for its whole length down to the bone. The bridge 
of muco-periosteum between the incision and the cleft is then stripped off 
the bone with a blunt raspatory completely into the cleft throughout its 
whole length ; this must be done most thoroughly, so that there is no tension 
upon the flaps, which, however, must not be bruised more than can possibly be 
helped. The sutures are then passed as in the operation upon the soft 
palate and twisted up. 

In case of operation upon the soft palate alone we prefer the plan of 
paring the edges first, then passing the sutures, and then dividing the muscles 
before twisting the sutures ; while in uranoplasty the edges are first pared, 
then the flaps raised, and lastly the sutures are passed and twisted up. 

In quite young children it is an advantage, if there is a complete cleft of 
both hard and soft palates, to close the soft palate alone first and some months 
after to close the hard ; the union of the velum tends to draw together the 
sides of the hard palate during growth and makes subsequent closure of the 
cleft more easy. Operation on a complete cleft of both hard and soft palates 
should be reserved for older children, who can better bear the increased 
severity of the more extensive operation. We usually do the whole opera- 
tion at once. 

The shape of tlie palate arc/i, already alluded to, is of importance ; the 
higher and narrower the arch the easier in most cases is the closure of the 
cleft, since there is proportionately more tissue to turn across the gap. 

In some children the cleft is so wide, that is, the failure of growth of 
the palate processes is so marked, that it is impossible to close the opening- 
by a plastic operation ; in such cases an obturator should be fitted to the 
gap. Operation is, however, nearly always practicable. 

In some instances the deficiency may be lessened by operation, even 
though complete closure is impossible ; a smaller obturator is then sufficient. 
Obturators are liable to increase the size of the opening by pressure 
unless carefully managed. 1 

The results of the operation arc, in successful cases, that the power of 
swallowing is improved, the food no longer tending to pass into the nasal 
fossa\ and the tendency to pharyngeal catarrh is Lessened. The voice is not 
improved by the operation itself, but closure ot tin- cleft renders it possible 
by subsequent training to greatly improve speech ; and if sufficient care ; s 

1 Coles' modification o( Suersen's is probably the best obturator. Vide 
Jour, November 1, [882. 



1 66 



Diseases of the Digestive System 



perfect ; this no training can do while 



taken it may be rendered practical 
the cleft remains. 

Mr. Mason's plan of completely dividing the soft palate backwards is 
devised to remedy the rigidity of the velum, sometimes resulting after opera- 
tion, which interferes with speech and deglutition. 

A high-pitched roof to the mouth sometimes produces exactly the same 
effect upon speech as a cleft palate ; this has been treated by Mr. Warrington 
Haward by loosening the muco-periosteum and excising a strip : the edges 
of the wound are then brought together so as to lower the pitch of the arch. 
Much improvement followed in his case. 1 

Other Malformations. — The rarer forms of congenital malformation 
of the lips require little more than mention here. 

A median fissure of the upper lip is of extreme rarity, but does occur ; it 
results from complete suppression of the lower part of the prefrontal process - 

(vtdepp. 157, 158). 

Cleft of the lower lip has 
occasionally been met with, 
as well as a peculiar mammil- 
lary projection on each side 
of the middle line. In one 
instance the cleft ran down- 
wards from the angle of the 
mouth. Murray is quoted 
by Mason as having seen a 
case where (congenital sac- 
culi existed in the lower lip in 
four members of one family. 
A similar case is recorded 
by Sympson in the ' Brit. 
Med. Jour.' December 9, 
1882. We have also seen 
more than one of these cases. 
Xttacrostoma, or congenital enlargement of the mouth, is usually uni- 
lateral, occurs most commonly in females, and is not hereditary ; it may be 
associated with branchial fistulae and supernumerary auricles together with 
hare-lip, as in a case of our own. In Guersant's case, figured by Mason in 
' Surgery of the Face, : the deformity was bilateral and clearly due to failure 
of union of the superior maxillary with the fronto-nasal and external nasal 
processes, i.e. persistence of the lachrymal fissure. 3 In the more usual form 
it is a persistence merely of the great buccal aperture from incomplete fusion 
of the superior and inferior maxillary plates, i.e. of the maxillary process of 
the pterygopalatine arch and the lower part of the mandibular arch from 
which Meckel's cartilage and the lower jaw arise. The condition is easily 
remedied by paring and uniting the edges of the fissure to the required extent. 
XVXacrocheilia, or enlargement of the lips, is occasionally met with as a 

1 Lancet, January 15, 1887. 

2 For a discussion on this subject, see Mr. Bland Sutton's admirable lectures, Lancet, 
February 18, 1888, and Tumours, Innocent and Malignant, 1893. 

5 Vide also figs, in Forster's Missbildun^en des Menschen. 




Fig 



-Macrostoma on the left side, with a faint 
scar-like mark leading up towards a depression at 
the base of a well-marked supernumerary auricle. 
(Mr. Southam's case.) 




Macrocheilia — Microstoma— Macroglossia 1 67 

congenital condition due to lymphatic overgrowth or enlarged mucous glands 
(cf. also N^VUS). When the deformity is sufficiently serious to require treat- 
ment, a part of the lip may be removed either by taking out a wedge-shaped 
piece of the whole thickness of the lip or by splitting the lip and removing 
a part of its thickness and afterwards stitching together the skin and mucous 
membrane. 

microstoma, or congenitally small mouth, is occasionally seen, and even 
•complete closure— atresia. This is treated by enlarging the opening to the 
necessary extent, stitching together the mucous and cutaneous borders, and 
at the corners bringing a flap of mucous membrane across the angle to the 
skin. Similar operations may be performed in cases of cicatricial contrac- 
tion after ulceration, burns, &c. 

In very rare cases the tongue is congenitally absent. 

A common deformity, though not nearly so common as it is popularly 
supposed to be, is tongue-tie or congenital shortness of the fraenum. Where 
this really exists the tip of the tongue is so tied down to the floor of the 
mouth and inner surface of the jaw that it cannot be protruded, and sucking 
is materially interfered with : slighter degrees of the deformity often exist, 
while in rare cases the tongue is so bound down to the floor of the mouth as 
to be practically immobile (anchyloglossus). Tongue-tie is easily recognised 
by pushing up the tip with the finger in the child's mouth ; its treatment 
consists in snipping through the edge of the fraenum with a pair of blunt- 
pointed scissors and then tearing the rest with the finger nail while the 
tongue is pushed upwards. The division should be made near the jaw, and 
should not be too free, or possibly the ranine vessels might be injured, or even, 
it is said, 'tongue-swallowing' occur, from loosening of the tongue muscles 
in the child's subsequent efforts at sucking. A more probable clanger is the 
occurrence of cellulitis. 

Sometimes the tongue is malformed, cleft in the middle line, or even 
trilobed, 1 or the muscles of one side may be deficient,'- e.g. as sometimes 
in facial hemiatrophy. 

Sublingual cysts may develop in the median line between the genio- 
hyo-glossi as a result of persistence of the lingual duct which runs from the 
foramen caecum towards the isthmus of the thyroid ; the cavity of these cysis 
is lined with epithelium and contains fatty material :! {vide p. 170). 

macroglossia is the term applied to a congenital affection of the tongue 
in which the normal lymph spaces are greatly enlarged and there is also an 
overgrowth of the connective tissue of the part ; there is, in fact, congenital 
lymphangiectasis. The result of this is great enlargement of the tongue, 
which may be kept protruded from the mouth to varying degrees, and by it> 
bulk and unwieldiness interferes with sucking and breathing. We have also 
met with slighter degrees of the same condition affecting only the sublingual 
tissue and resembling ranula. Associated commonly with macroglossia is 
hygroma or one form of 'hydrocele of the neck.' This is simply a similar 
•condition of the lymphatics of the floor o\ the mouth and upper part of the 
neck. It appears as a soft, doughy swelling in the submaxillar} region, and 

1 Barling, Brit. Med. Jour. December 5. 1885. 

2 Choletin Billard's Maladies de I Enfance. 

3 Bland Sutton, Brit. Med. Jour. February 27, [886. 



1 63 Diseases of the Digestive System 

may reach a large size, occupying the greater part of the sides and front of 
the neck {vide chapter on Tumour Growth). 

In severe cases these conditions rarely admit of successful treatment, the 
children are generally marasmic and often otherwise malformed. Removal 
of part of the tongue with the ecraseur or excision of a wedge from it with 
subsequent closure of the gap may be attempted. Galvano-puncture, electro- 
lysis, setons, and injections are all worth thinking" of, and pressure and astrin- 
gents are said to have done good in some instances. It must be remembered 
that hygroma sometimes spontaneously disappears. 

Slighter degrees of the deformity are occasionally met with in older 
patients : in them the condition has a less obvious connection with the 
lymphatics, and appears to be sometimes mere overgrowth of the mucous 
and connective tissues. 

Ranula is the result of occlusion of a mucous duct and the formation 
of a retention cyst, rarely it is due to obstruction of a sublingual salivary duct. 
It appears as a bluish-grey translucent swelling beneath the tongue ; it 
is soft, fluctuant, and painless, but produces deformity from pressure of the 
tongue upwards and the floor of the mouth downwards, and, if large, interferes 
with speech and deglutition. The swelling contains a clear glair}- fluid like 
white of egg. Ranula may be treated by excision of a part of the cyst wall 
or by passage of a seton through it ; both methods are frequently successful, 
but sometimes fail ; if they do the greater part of the cyst wall should be 
clipped away with scissors and the surface remaining be well scraped or 
rubbed over with solid nitrate of silver. Relapse is believed to be sometimes 
due to the cyst being multilocular, Rarer forms of ranula are those due to 
enlargement of a bursa beneath the mucous membrane (bursa of Fleisch- 
mann), or of the one between the genio-hyo-glossi muscles— these may con- 
tain melon-seed bodies. Ranulae connected with the submaxillar}- duct have 
often been described, but their existence is more than doubtful ; the duct can 
always be made out lying on the surface of the cyst. Congenital dermoid 
cysts in connection with the branchial clefts are sometimes met with in the 
floor of the mouth : they may attain a large size or remain stationary for 
years ; they contain the usual sebaceous matter, hair, £:c. 

A form of cyst arising in connection with the lingual duct which runs from 
the foramen caecum towards the hyoid bone has already been mentioned. 
It is due to persistence of the pharyngeal diverticulum from which the thy- 
roid gland is developed, the thyreo-glossal duct. Vide ' Median Fistulas of 
Xeck, ; p. 170. The dermoid and bursal cysts are to be treated by free 
incision, with scraping and subsequent drainage ; in some cases the cyst 
requires dissecting out through an incision below the jaw. 

Other Affections of the Tongue. — Papilloma and condyloma of the 
tongue are not rarely seen, as well as naevi and mucous retention cysts. 
Papillomata ma)- be snipped off, condylomata require of course specific 
treatment, mucous cysts should be treated like ranula. 

Naevus of the tongue is not rare (vide chapter on X.evi) ; puncture with 
the actual cautery is usually the best treatment, but excision of part of the 
tongue may be required. 

Mason has described congenital pendulous fibro-cellular tumours of the 
tongue. 



Branchial Fistulce \6ty 

Hypertrophy and Atrophy of the Face. — In some cases one side of 
the face is congenially hypertrophied, and continues to grow more rapidly 
than the other side. Nothing can be done for this deformity unless, perhaps, 
ligature of the external carotid were tried. 

Congenital Atrophy, or rather arrest of development of the face, is also 
occasionally seen ; most often it is the result of either some cerebral deficiency 
or of some unilateral lesion, such, for instance, as torticollis ; it may occur as 
an acquired deformity resulting from injury. 

Congenital atresia of the mouth has been already mentioned, but in some 
cases the obstruction is not at the lips, but at the level of the pillars of the 
fauces, and is clearly due to non-absorption of the septum marking off the 
buccal involution from the pharynx. If this rare condition is met with, 
probably free incision and dilatation would relieve the obstruction. 

Actual absence of the mouth with deficient development of the facial 
bones, and instances of apertures below the natural position or on the cheek, 
have been met with. ( Vide Billard, op. cit.) 

Ballard has recorded a case of deformity of the jaws produced by thumb- 
sucking, the upper jaw being drawn forwards, and the lower depressed so 
that the face is ' overhung.' l 

Branchial Fistulse. — Small orifices large enough to permit the passage 
of a fine probe for distances varying from a quarter of an inch to two or three 
inches are sometimes met with in the neck on one side of the middle line. 
They may occur in the immediate neighbourhood of the external ear or lower 
down in the neck ; the most common position is said to be just above the 
sterno-clavicular joint. The fine channel continuous with these openings 
usually runs upwards and towards the middle line. A little watery mucous 
discharge is often secreted from glands lining the interior of the passage, and 
it is said that occasionally there is a distinct communication with the pharynx. 
These fistulas, which are often hereditary, may be single, or there may be 
two or three of them, and they may be symmetrical. Fragments of cartilage - 
may be found in their neighbourhood, and it is possible that pharyngeal 
diverticula may result from patency of the internal orifice. 

The presence of these fistulas is due to imperfect obliteration of the 
branchial clefts of embryonic life. 

While the cervical branchial fistulas are rare, it is quite common to see 
children in whom there is a small pendulous body, like a molluscous growth, 
upon the cheek just in front of the external car. Sometimes there is more 
than one of these, and very often at the base of the little body is a minute 
orifice leading a short distance inwards. We have most often seen these 
'supernumerary auricles,' as they are called, unassoeiated with any other 
deformity; but in one instance the child, which had several of these auricles. 
had also macrostoma, double hare-lip, and cleft palate, and a small pendulous 
body exactly like one of the auricles upon the tip of the nose. Our friend 
Mr. Southam has recorded a somewhat similar ease (fig. 22), and Mr. J. 11. 
Morgan another. Cervical 'auricles' .ire also met with (vide tig. 23 . 

The cervical branchial fistulas represent the clefts between the hyoid am! 

1 Path. Soc. Trans, vol. xv. 

- Treves records a oiso in which a rod o( cartilage existed, but no fistula [P 

November 1, 18S7). 



170 Diseases of the Digestive System 

thyrohyoid arches, or between the thyrohyoid and subhyoid, or again between 
the subhyoid arch and the upper boundary of the chest, while the presence of 
aural fistula occurring, as it sometimes does, in the helix or elsewhere, is due 
to persistence of one or more of the fissures between the ' tubercles ; of which 
the pinna is built up. 1 the supernumerary auricles themselves representing 
displaced or ununited " tubercles/ 

The common ' supernumerary auricles, which may or may not have a little 
pit at their base, 1 are thought by Sir J. Paget to be probably growths of the 
same opercular skin fold as the auricle, from which they look like bits de- 
tached, or they are auricles displaced, but still in the line or region of the 
mandibular arch.'- 

The auricles, sometimes at least, contain cartilage, and the association of 
enchondroma of the parotid occurring in later life with disturbance of the 

development of these parts has been 
pointed out by Mr. Jacobson. 3 

In very rare instances an orifice is 
met with in the median line of the neck. 
Of this we have seen four cases, two of 
our own and two in the practice of our 
colleagues ; in one there was a seam in 
the skin closely resembling the scar of 
a tracheotomy wound, and in the centre 
of this, just above the sternum, was a 
small opening ; in the second case there 
was a discharging fistula over the lower 
part of the thyroid cartilage. These 
median apertures ma}' be explained by 
failure of the branchial arches to close 
in the middle line, or possibly by a 
deficient closure of the ' sinus cervicalis." 
It is. however, most probable that such 
a fistula, the ' thyro-glossal duct : or 
; canal of His/ is. in the words of Dr. C. F. Marshall, who has kindly sent 
us his paper on the subject, ' a remnant of the middle thyroid rudiment of 
His. It is not difficult to imagine.' he says, ' that this may gradually become 
dilated at its lower end into a sac by the secretion of mucus from the wall of 
the canal, and that this sac ultimately causes the skin to give way by its pres- 
sure till a sinus is formed.' Dr. Marshall, in his interesting paper, points out 
that these fistulae are not present at birth, but appear later, a strong point in 
support of his view, which is now generally accepted. 4 

As these branchial fistulae give rise to very little inconvenience, it is usually 
best to leave them alone, especially as they are intractable to treatment from 

1 Vide Mr. Bland Sutton's Lectures, Brit. Med. Jour. February 19, 1887, and L 
Tebruary 1888, and his book on Tumours, 1893. 

2 SirT. Paget \Med.-Chir. Trans. 18781, from whose writings much of our information 
on the subject is taken. 

5 Vide Guy's Reports. 

4 Vide Sir'j. Paget, op. cit. ; also Tillaux and others, Lc Prcgros Medio. February 21, 
1885; Dr. C. F. Marshall, Jour, of Anat. and Phys. vol. xxvi. ; also St. Thomas's 
H; Hal Reports, 1890, and Brit. Med. Jour. May 1890. 




Fig. 23. — Supernumerary auricle in the neck. 



Branchial Fistula?, &c. iji 

the difficulty of thoroughly destroying their secreting surface. The passage 
of a hot wire down them, or passing a probe in and then dissecting round it, 
or the use of the galvanic cautery, is the plan usually advised. In the 
second of our median fistulae, in which there was a ' pinching' pain in the 
part, we with some trouble succeeded in obliterating it for a time by several 
applications of nitrate of silver fused upon a wire and passed well up the 
track ; subsequently, however, fresh secretion occurred, and even excision 
failed to entirely cure the condition ; however, complete excision of the whole 
fistulas is the only at all certain method of cure, and this may involve a 
somewhat troublesome dissection. 

Supernumerary auricles should be simply snipped off. They consist of 
a small rod of yellow elastic cartilage covered with integument, and are 
supplied with a small artery. 

Instead of fistulae, congenital dermoid cysts may be found marking the 
sites of the various fissures &c. of the embryo {vide chapter on TUMOUR 
Growth). Clutton has described a case of congenital papilloma in the line 
■of the branchial fissures ; and cases of primary carcinoma in the neck, pro- 
bably taking origin in relics of the branchial clefts, have been recorded. 

In some of these patients the lower jaw is imperfectly developed. 

By far the best account of the various developmental abnormalities will 
be found in Bland Sutton's interesting 'Tumours, Innocent and Malignant :' 
Cassell & Co. 1893. 

Any part of the digestive tract may be the seat of congenital malforma- 
tion in addition to those already described. Congenital strictures 1 and 
pouchings 2 of the oesophagus, tracheal fistula, 3 displacements of the stomach, 
obliteration of the pylorus, absence of portions of the intestinal canal, and 
displacement of its various segments, are all met with, and in certain cases 
may have some surgical importance ; they cannot, however, be discussed 
here. Enterotomy might possibly be of service in some cases of congenital 
intestinal deformity where the obstruction was low down {vide p. 140). 

1 Charlewood Turner mentions seven cases in Ziemssen. Vide Path. Soc. Trans. 
1885. 

2 Sir Morell Mackenzie states that congenital pouching is extremely rare. 

5 May be combined with oesophageal deficiency usually at the middle third of the 
.gullet. The fistula is a persistence of the embryonic condition (Sir M. Mackenzie). 



■ 



Diseases of the Liver 



CHAPTER X 

DISEASES OF THE LIVER 

In examining the liver of an infant or young child, it must be borne in mind 
that this organ is proportionately larger in the child than in the adult ; it con- 
sequently occupies a greater space in the abdominal cavity, and thus to the 
inexperienced it may appear to be enlarged, when in reality it is only of 
normal size. The fact pointed out by Sahli must not be forgotten, namely, 
that the angle made by the lower ribs with the tip of the sternum is wider in 
children than adults, so that more of the liver is left uncovered in the former 
than in the latter. This may lead to the liver appearing larger than it really 
is. The upper limit, as determined by percussion (superficial dullness), reaches 
to the fifth space at the right edge of the sternum, to the upper border of the 
sixth rib in the nipple line, the seventh in the axillary, and the ninth pos- 
teriorly, though the deep dullness reaches somewhat higher. While the edge 
of the right lobe does not in an adult extend below the costal arch in the 
recumbent position, in a child it always does. The size of the liver can be 
as readily estimated in a child as in an adult by percussion if the stomach is 
not over-distended ; the lower edge can, however, be much more readily felt 
in a child than in an adult by placing the warm hand on the abdomen and 
gently pressing backwards and upwards. In most cases it can be easily 
determined if the edge is round or sharp or irregular. 

The liver is not often smaller than natural during childhood ; it is so only 
in the rare instances of the occurrence of acute yellow atrophy or cirrhosis,, 
and even in these cases it is by no means always diminished in size ; indeed, 
it is frequently enlarged, a result which is due partly to its vascular nature, 
its veins being very readily distended, and partly also to the ready way in 
which it appears to store away fat. 

The best instance of its enlargement from mechanical causes is afforded 
by the congestion which so frequently attends heart disease, where, in conse- 
quence of regurgitation through the mitral valves, there is an obstruction to 
the onward flow of the blood. It is enlarged also in mediastino-pericarditis 
for a similar reason. There appears also often to be a temporary enlargement 
and a sluggish circulation in many cases of chronic intestinal catarrh, where 
there is said to be a functional derangement of the liver, accompanied by loss 
of appetite and pasty constipated stools deficient in bile and an excess of 
pigment and perhaps uric acid in the urine. The liver is frequently enlarged 
from the presence of excess of fat ; more rarely it is amyloid, or the seat of 
new orrowths or of abscess. 






Con gen it a I Jaundice 1 7 3 

Jaundice. — The common form of jaundice occurring in newly born 
infants has already been discussed ; the rarer form in which jaundice is due 
to lesion of the bile ducts may be here referred to. 

Congenital Stricture or Obliteration of the Eile Ducts. — In these 
curious cases an obliteration of the common hepatic ducts appears to take 
place, which leads to a secondary or biliary cirrhosis of the liver if the infant 
survive for a few months. The child may die from haemorrhage from the 
navel or gastro-intestinal canal during the first few days of life. Such cases, 
though not common, are by no means rare. Among the more recently recorded 
cases are those of Wickham Legg and Glaister ; we have seen two cases in 
which autopsies were made. 

Symptoms. — The infant is jaundiced from birth, the yellow colour being 
intense, affecting the skin, conjunctivae, mucous membrane, and urine ; the 
stools are pale and completely devoid of bile. The infant frequently suffers 
from haemorrhages, the stools then being black and the skin covered with 
•ecchymoses. In one of our cases the motions were stated by the mother to be 
black immediately after birth. The liver may be enlarged. Such children 
may live for a few months ; both of our cases lived to be 4^ months old. 
The following case illustrates some of these points : 

Congenital Absence of Hepatic Ducts. Biliary Cirrhosis. — John H., aged 6 weeks, 
was brought to the out-patient department on October 4, 1883, with the following his- 
tory : Mother states he was an eight-months child, born after a tedious labour. About a 
week after birth it was noticed he was jaundiced (midwife states he was yellow when 
born) ; his urine was dark and stained the linen ; the stools were loose and pale grey in 
colour; he did not ' snuffle, ' and there never was any rash. On examination, when 
6 weeks old, he was deeply jaundiced ; fairly well nourished ; the edge of the liver was 
felt immediately below the ribs. October 8. — Much the same; diarrhoea troublesome, 
pale white milky stools. October 25. — The liver is enlarged, the edge being felt nearly on 
a level with the umbilicus ; it has been increasing in size the past week or two. Novem- 
ber 1. — Liver still enlarged; stools loose, resembling milk; still intensely jaundiced ; is 
becoming very thin. December 6. — Liver decidedly less ; diarrhoea not so troublesome ; 
■continues to waste. December 30. — Diarrhoea has been very troublesome ; convulsions. 
Death when 4 months old. He had not at any time suffered from purpura or haemor- 
rhages. 

Post-mortem. — Body extremely emaciated and deeply jaundiced ; all internal tissues 
bile-stained. Heart, muscular walls pale yellow ; kidneys ditto. Liver, 7 oz. ; does not 
appear enlarged ; is of a dirty dark green colour, surface finely granular ; no adhesions or 
peri-hepatitis or matting of parts in the fissure ; it has a tough feel, and creaks under the 
knife as it is cut ; the section shows a dark green colour with strands of fibrous tissue, much 
in excess of the normal state, accompanying the portal vessels ; the strands arc best marked 
near the entrance of the vessels at the fissure, and the larger bile channels are more or 
less dilated and contain thick green bile. On examining the inferior surface of the liver, 
the gall bladder is seen distended with a non-biliary mucoid fluid ; its duets can be traced 
downwards, though smaller than normal, to the ductus choledochus ; the latter joining the 
duodenum in the normal position is pervious and contains mucus only. No trace of a 
right or left hepatic duet can be found. The portal vein ami hepatic artery are apparently 
quite normal. Microscopical examination of liver shows excess of fibrous tissue sur- 
rounding portal vessels and lobules; many small biliary ducts are seen choked with 
inspissated bile. 

Diagnosis. — The obstructive jaundice o[ the newly born cm bo readily 

distinguished from functional jaundice, the only form likely to be confounded 
with it, by the stools in the former being colourless while the latter contain bile. 



174 Diseases of the Liver 

Moi'bid Anatomy. — There is much emaciation, the internal organs are 
intensely bile-stained, with minute haemorrhages on their surfaces. The 
liver is mostly enlarged and of a dirty green colour ; the surface is granular, the- 
granulations varying in size from a millet seed to a hemp seed : it has a tough 
feel, and on section an excess of fibrous strands is seen accompanying the 
portal vessels — this is most marked at the great fissure ; the larger biliary 
channels contain green inspissated bile. On examining the vessels in the 
transverse fissure, the vein and artery are intact, but the gall bladder is usually 
small and contains no bile, and the common and hepatic ducts are either shri- 
velled up and nearly obliterated or greatly diminished in size. Microscopical 
examination of such livers shows biliary cirrhosis. The etiology of these 
cases is obscure ; in some cases apparently the ducts are never formed. In 
one of ouf cases the mother had suffered from syphilis, but neither of the 
infants showed any symptoms. It is possible that a catarrh of the bile-ducts 
occurring during fcetal life or a blockage from inspissated bile might lead to- 
a permanent obstruction and obliteration. The cirrhosis follows as a result.. 

Prognosis. — Such cases are necessarily fatal in a few months, and hardly 
admit of any treatment. 

Catarrhal Jaundice 

Children of all ages are apt to -suffer from a temporary jaundice, asso- 
ciated with gastro-intestinal catarrh, attributable to a swollen condition of 
the mucous membrane of the duodenum and common bile duct. 

Syjnptoms. — After a few days, in which there are symptoms of dyspepsia^, 
the conjunctivae and skin become yellow, the urine contains much pigment,, 
and the stools are pale. A few days later the liver may be felt to be en- 
larged. There are rarely the nausea, low temperature, and slow pulse so often 
seen in the catarrhal jaundice of adults. We have, however, seen one or 
two cases in which there were jaundice, delirium, drowsiness, and slight fever^ 
in which we suspected acute yellow atrophy, yet they finally recovered, and 
we were left in doubt as to their nature. As a rule, in the course of a few 
days or a 'week all the symptoms disappear. 

The diagnosis of catarrhal jaundice does not usually give rise to difficulty 
when it occurs in children. The possibility of the jaundice being due to 
acute yellow atrophy must be borne in mind, and any ecchymoses or brain 
symptoms would be very suggestive of the latter. Jaundice due to cirrhosis,, 
or new growth, or syphilitic disease, could hardly be mistaken, as jaundice 
under these circumstances would not be an early symptom. It is possible- 
that jaundice may be due to round worms finding their way into the duode- 
num, and entering the common duct. 

Treatment. — The treatment of catarrh of the bile-ducts should be similar 
to that of gastric catarrh : the diet consisting of beef tea, bread sops, light 
puddings, and milk. Sulphate or phosphate of soda may be given with infu- 
sion of rhubarb two or three times a day. Carlsbad salts or Friedrichshall 
water is useful in keeping the bowels open. 

Acute Yellow Atrophy of the liver 

This curious and interesting disease appears to occur at all periods of 
life, infancy and childhood not excepted. Several Continental writers have 



Acute Yellow Atrophy 175 

described cases occurring in infants a few days old, but whether these were- 
in reality true cases of yellow atrophy may be open to doubt. Undoubtedly, 
infants who are jaundiced shortly after birth die in the course of a few days 
or weeks with symptoms of acute disease, but, as far as can be judged from 
the reports, the naked-eye appearances of the liver after death were not 
those usually found in acute yellow atrophy. In such obscure diseases as 
those named after Buhl and Winckel, jaundice occurs. While this disease 
cannot be said to be common at any time of life, it is perhaps rarer in 
childhood than in early adult or middle life, though it is very probable that 
cases are not infrequently overlooked, inasmuch as some of the recorded 
cases were not diagnosed during life. That they are not rare is certain, as 
Dr. Hyla Greves has collected seventeen cases besides one observed by 
himself. We have seen two cases, one of which occurred in a boy of 4 
years, and we have had the opportunity of examining the liver in a case of 
Dr. Railton's. 

Symptoms. — The disease begins insidiously ; the first symptoms are 
chiefly those of catarrhal jaundice, loss of appetite, constipation, and jaundice, 
the stools are mostly pale but sometimes quite normal, and the urine is bile- 
stained. The patient usually remains in this condition for a week or two, 
during which time neither his friends nor medical attendant suspect the 
serious nature of the disease. The liver at this period is enlarged and in 
some cases distinctly tender. Then come distinct cerebral symptoms which 
may not improbably be mistaken for the onset of tubercular meningitis. The 
child is irritable, vomits repeatedly, rambles at night, is perhaps very 
delirious or convulsed ; the pupils are generally dilated. There are often 
ecchymoses about the body at the seat of slight injuries, and oozing of blood 
from the gums and oedema of the feet and face. After a few days the child 
passes into a condition of coma ; there are also probably muscular twitchings, 
spasms of several groups of muscles, as the masseters, and perhaps local 
paralyses. The urine may contain leucin and tyrosin. In the later stages 
the liver diminishes in size, but this is not invariably the case. The following- 
case illustrates some of these points : 

Acute Yellow Atrophy of Liver. — Stephen T. , aged 4 years. Admitted September 27, 
1882. Mother dead. No history of congenital syphilis could be obtained. Father is a 
labourer in poor circumstances. Child has been much neglected, and often had insufficient 
food. Four weeks before admission child took very little nourishment ; became yellow 
and was constipated. Fourteen days ago vomiting began, and lately he had been delirious 
at night and queer in his ways. Present state. — Patient is a well-developed boy ; moderate 
jaundice ; there is oedema of both eyelids, back of hands, and dorsum of both feet. He 
is frequently mumbling to himself, and does not readily understand what is said to him. 
His tongue is red at the tip and edges and coated on dorsum ; he is very thirsty, but 
almost constantly vomits his milk immediately after it is taken. Abdomen somewhat dis- 
tended ; edge of liver distinctly felt below costal arch and in epigastrium, and on per- 
cussion dullness extends upwards to the fourth space. The tip of the spleen is felt below 
the tenth rib. Heart's sound normal ; no marked physical sign in chest. Trine passed 
with faeces or in bed ; some separated from faeces contained bile pigment ; no albumen ; 
no leucin or tyrosin under microscope. Faeces, passed a few hours after admission, were 
solid and of a dark brown colour. Pupils dilated, but act to Light. Pulse, 100, weak ; 
temperature, >.<> F. Second day (of admission). Vomiting continued most of day, but 
less after peptonised milk was given. Temperature, 96'4°-ioo'2°, Third day. Less 
vomiting; haemorrhage from mouth, apparently from gums; bowels acted once aftei 



176 Diseases of the Liver 

calomel, solid brown motion ; no urine passed for twenty-four hours. Temperature, 
95 c -ioi*2°, 97*8 3 -io2 , 8 :> . Fourth day. — Child has been delirious, with some muscular 
twitchings of face and neck. This morning, left facial paralysis noticed not affecting the 
eve ; it is well marked when child cries, but not complete ; no paralysis elsewhere ; pupils 
dilated and sluggish ; child only semi-conscious ; several loose stools passed after calomel, 
the first light yellow, later pale grey colour ; no urine obtained ; edge of liver very dis- 
tinctly felt below costal arch. Pulse, ioo, weak ; temperature, io2 , 8°, 104 , io2"6°, ioi°. 
Fifth day. — Much worse ; is quite unconscious ; head and eyes turned to right ; all limbs 
extended and rigid ; spasms of jaws causing constant grinding of teeth ; breathing 
stertorous ; no optic neuritis, but veins are full and somewhat tortuous. Pulse, 130, weak ; 
temperature, ioi"2 -ioo°. Died in afternoon. 

Post-mortem (twenty-two hours after death). — Body well nourished ; skin very yellow ; 
much hvpostatic congestion of dependent parts of the back and arms and legs ; ' coffee- 
ground ' material oozing from mouth ; no rigor mortis ; slight oedema ; a bruise about 
size of a penny is visible on the sub-clavicular region, left side. Chest : no fluid, old 
adhesions left side ; right lung on section showing numerous small haemorrhages into sub- 
stance of lung ; both lobes are gorged. Left lung : there is a solid portion in upper 
lobe, reaching anterior surface and corresponding in a position with above-mentioned 
bruise, involving the whole thickness of the lobe, but not the inner or outer edges. On 
section this solid portion consists of red hepatisation with a blood clot in centre and at 
circumference ; lower lobe gorged and containing small haemorrhages. Bronchi contain 
blood and mucus. Heart, 2^ oz. : left side contracted, containing a few strings of yellow 
fibrin ; walls of heart pale yellow and fatty ; no endocarditis ; haemorrhages into sheath of 
aorta. Abdomen : on opening, a few ounces of bile-stained fluid escaped. Much injection 
of small vessels of mesentery in the neighbourhood of the liver ; one haemorrhage, size 
of walnut, in mesentery of descending colon. Stomach contained coffee grounds ; 
duodenum also darkish contents ; rest of small and large intestines contained pale yellow 
semi-fluid contents. Spleen, 3 oz., firm : somewhat enlarged but normal. Kidneys. 
4^ oz. : cortex pale yellow, and has a glistening appearance from presence of fat ; pyramids 
congested. Brain : nothing normal at base, but convolutions on upper surface are 
decidedly flattened ; the ventricles are distended with turbid fluid, and the parts around, 
especially the white portions, are softened and easily wash away under a stream of water ; 
no lesion of pons or softening noted elsewhere ; no haemorrhage. Liver, 12^ oz. : it is 
very limp, and capsule wrinkles on doubling up. Right lobe : upper and lower surfaces 
are irregular from presence of some portions which are more elevated than others ; the 
more elevated portions are greenish yellow, and the others red. On section, bright 
orange-yellow and red portions are seen ; the lobules are not readily seen in the yellow- 
parts, which are soft. In the red, which are firmer, the lobes can be distinguished, the 
centres being bright red and the circumference pale. The left lobe contains more of the 
red parts and the right more yellow. Microscopical examination. — Red portions, the 
intralobular veins are normal, the walls of the interlobular veins contain numerous 
leucocytes, and the surrounding connective tissue is also infiltrated ; the lobules contain 
no hepatic cells, but hyperplastic stroma, leucocytes, many red corpuscles. The biliary 
•capillaries are very prominent objects, and seem to contain epithelium with nuclei under- 
going subdivision. Yellow portion — The lobules are large ; central vein normal ; hepatic 
■cells swollen ; nuclei obscured ; fine granular contents and bile pigment. The walls of 
[interlobular veins infiltrate with leucocytes. Biliary capillaries stuffed with epithelium. 

Diagnosis. — Malignant jaundice in an early stage cannot be distinguished 
from catarrhal jaundice ; it is only when cerebral symptoms appear, and 
there are dilated pupils, ecchymoses, or constant vomiting, that the suspicion 
is raised that there is something more than simple jaundice. At this time the 
case is liable to be mistaken for meningitis, though the presence of jaundice 
and cerebral symptoms should indicate the true nature of the disease. It 
imay possibly be confounded with pyaemia, phosphorus poisoning, or pneu- 



Cirri w sis of Liver I yy 

monia with jaundice, but in all these the jaundice would as a rule follow and 
not precede the other symptoms. 

Morbid Anatomy. — Organs bile-stained ; haemorrhages in various organs. 
Liver small, limp in texture, mostly bile-stained, some portions being greenish 
yellow, others orange-red, often bulging in some parts from shrinking in 
others. On section, there are usually areas of red or yellow colour in which 
the lobules are indistinct or entirely indistinguishable. 

Treatment. — Unfortunately but little can be said under this head, as 
such cases have been invariably fatal. 



Cirrhosis of liver 

Alcoholic. — A typical hobnail liver due to alcoholism is necessarily rare 
during early life, as it is hardly likely that it will often happen that a child 
has many opportunities for indulging in alcoholic drinks to any excess. 
Cases of this sort have, however, been reported by Continental writers, and 
a few in this country and also in America. Dr. Wilks relates the case of a 
girl of 8 years who had taken daily for some time half a pint of gin ; she 
eventually suffered from ascites, and at the post-mortem a small hobnail liver 
was found. Cases of cirrhosis have been reported by Frerichs, Bamberger, 
Howard, and others, in which there was a history of alcoholism. Mitchell 
Clarke l reports two cases of cirrhosis of the liver in children, in which there 
was no history of syphilis, tubercle, or alcoholism. As the symptoms of 
alcoholic cirrhosis when it occurs in childhood are the same in children as 
in adults, no special description is needed here. 

Syphilitic Cirrhosis. — Syphilis is by far the commonest cause of inter- 
stitial hepatitis occurring during early life ; though in a large proportion 
of cases it is found in the post-mortem room in cases in which it was not 
diagnosed during life. In syphilitic infants who are born dead, or who 
die within a few months of birth, the liver is sometimes found to be en- 
larged and firmer than usual, the surface is perhaps smooth, but the liver 
cuts as if of leathery consistence, and the cut surface shows the acini to 
be less distinct than normal, and bands of fibroid tissue may be seen 
running through the liver substance. In some cases there are no very 
characteristic microscopic appearances, and it is only on microscopical exa- 
mination that interstitial hepatitis is made out. In a well-marked case the 
section shows an excessive amount of connective tissue along the course of 
the portal vessels, and numerous spindle cells and embryonic tissue. In 
more advanced cases islands of fatty liver cells may be seen surrounded by 
newly formed connective tissue. The above appearances are so characteristic 
of congenital syphilis, that they arc diagnostic of syphilis when found post 
mortem, even in the absence of symptoms during life and other confirmatory 
evidence after death. Gubler has described another form ot syphilitic liver, 
in which there are miliary gummata present in the liver mostly about the 
size of pins' heads, scattered through the substance or situated in groups, in 
combination with interstitial hepatitis. The small gummata consist of small 
round cells, and are mostly connected with the smaller branches of the portal 
vein or biliary capillaries (Birsch Hirschfeld). There is often also thickening 

1 Brit. Med. Jour. June 30, [894. 

N 



178 Diseases of the Liver 

and thrombosis of the small vessels, the changes being similar to the arteritis 
found in syphilitic disease of the brain. In older children cheesy nodules 
and cicatricial bands of fibroid tissue are found on the surface of the liver, 
similar to those found in syphilitic disease of adults. There may be fibroid 
bands and cicatricial tissue in the great fissure and accompanying the portal 
vessels into the liver substance. In some cases there is a peri-hepatitis as 
well as an interstitial hepatitis. 

Symptoms. — In infants almost the only symptom is an enlarged liver, 
having perhaps a harder feel than normal, and in some cases more or less 
jaundice. In older children the liver may perhaps be felt to be enlarged and 
the edge irregular ; there will perhaps be other symptoms present that point 
to syphilis ; in a few cases there has been ascites from portal obstruction. 
Such cases have been described by Cheadle, Norman Moore, and Lewis 
Smith, of New York. 

Diagnosis. — The diagnosis of either alcoholic or syphilitic cirrhosis would 
be greatly assisted by a history of alcoholism or of syphilis, or in the latter 
case by other evidence of syphilis afforded by the patient. In older children, 
the presence of pegged teeth, interstitial keratitis, or scars about the mouth 
would naturally suggest that the enlarged liver present was syphilitic. In 
the absence of other evidence of syphilis in cases of ascites with enlarged 
liver, it is rarely safe to diagnose a syphilitic hepatitis, as both ascites from 
chronic peritonitis and portal obstruction from rnediastinitis are more common 
than syphilitic cirrhosis. In portal obstruction the spleen is mostly enlarged. 

Treatment. — Not much can be expected of anti-syphilitic remedies in 
syphilitic cirrhosis, as it is hardly likely fibroid tissue can be absorbed. Still 
it will be wise to give mercury and iodide of potassium by the mouth and 
apply mercurials locally. The ascites may be relieved by tapping. 

Miliary tuberculosis, malaria, chronic peritonitis, chronic heart disease, 
and rnediastinitis, may all give rise to interstitial hepatitis in a minor degree. 
In cases of rnediastinitis where there has been some obstruction to the flow 
from the hepatic veins, the liver becomes often enormously enlarged and 
sponge-like from the dilatation of the capillaries and small vessels, and there 
is an excess of fibroid tissue formed. 

Treatment. — The treatment of portal obstruction, the result of a cirrhotic 
liver, is only palliative, for there is but little reason to hope that even in syphi- 
litic disease there is much chance of modifying in any way the fibrous tissue 
which is strangulating the portal channels in the liver. Relief must be sought 
by unloading the portal system by purgatives and diuretics and by removing 
the ascitic fluid by tapping ; the latter is best performed by means of Southey's 
trochars. In syphilitic cases the local inunction of mercurial ointment and 
other specific treatment should be tried. 

Patty Liver 

The liver becomes enlarged from being infiltrated with fat in several 
different diseases during infancy and early childhood. It is common to find 
children who are fat, pale, and rickety, with large livers, the edge of the 
right lobe reaching nearly into the iliac fossa and the left to the umbilicus. 
If an opportunity occurs for a post-mortem examination, such livers are found 



Tuberculosis of the Liver 179 

to be pale and greasy, the lobules being indistinct, and the cells are seen 
microscopically to be loaded with fat. wSuch children are usually anaemic, 
have large distended abdomens, coated tongues, pasty stools, and suffer from 
chronic indigestion. Under a careful dietary, small doses of mercurials and 
salines, such as Carlsbad or Rubinat water, improvement gradually takes 
place and the liver diminishes in size. 

Tuberculosis of the liver 

Although it is exceedingly common to find tubercles in the liver in children 
dying of general tuberculosis, it is exceedingly rare for these tubercles to have 
given any indication of their presence during life. Tubercular disease of the 
liver generally takes the form either of grey miliary tubercles scattered through 
the organ and on the surface, or of cheesy nodules, rarely larger than peas or 
.at the most small marbles, which appear to have a special preference for the 
neighbourhood of the bile ducts. These caseous masses may be found bile 
stained on section, and small cysts formed of dilated bile ducts filled with 
inspissated bile may be found which have been caused by compression of the 
-ducts. Jaundice is rarely produced unless there are enlarged caseous glands 
in the transverse fissure compressing the common duct. In very rare instances 
caseous masses appear to form in the liver, resembling the caseous masses 
seen in the brain : these may cause enlargement of the liver and gradually 
soften down into a chronic abscess. We have seen only one case of this 
kind. The history was as follows : 

Chronic Tuberculosis. Hepatic Abscess. — Boy, aged 14 years, father and mother 
dead; never been out of England; admitted December 21, 1880; recently had pain 
in right side and cough ; an anaemic boy ; yellowish conjunctiva ; pain and tenderness 
about hepatic region ; dullness in right nipple line to fifth rib, and two inches below 
ribs. Temperature, 99°-io2°. January 13. — Slight albumen in urine; liver is larger, is 
tender to the touch and on percussion ; fine rales at base of right lung. Temperature, 
•95°-io3°. 20th. — Liver excessively tender, hepatic region bulging; left lobe halfway to 
umbilicus ; dullness at base of right lung to angle of scapula ; explored left lobe of liver 
with syringe, only obtained blood ; albumen in urine ; is wasted. 21st. — Fluctuation felt 
in liver ; aspiration — this time obtained an ounce or two of thick pus. 26. — Fluctuation 
decidedly felt ; opened antiseptically,"8 oz. of thick glairy pus, mixed with blood and 
bile ; tube inserted, followed during evening by large discharge of pus. 28th. — Has 
been very weak, vomiting ; left leg very cedematous for a day or two, now dark blue as if 
becoming gangrenous ; sudden death. 

Post-mortem. — Body emaciated ; pus swelling up from fistulous opening ; left leg much 
swollen ; some fluid in pericardium. Heart normal. Right lung adherent to diaphragm 
by lymph and fibrous tissue ; no pneumonia ; the diaphragm abnormally raised by the 
• enlarged liver below, and is adherent to it by recent lymph ; the liver has been punctured 
in the left lobe near its junction with the right on its upper and anterior surface. The 
fistulous opening enters a very irregular cavity containing pus : this cavity contains semi- 
solid cheesy material and irregular fibrous trabeculae, which give it a worm-eaten appear- 
ance ; posteriorly in the right lobe is a cheesy mass, size of an orange, beginning to 
become worm-eaten, and containing a little pus ; a few other irregular cavities joining 
together: no lardaceous change. Spleen enlarged, lardaceous. Intestines matted 
together by old adhesions, the mesentery containing cretaceous masses (old peritonitis 
from suppurating glands) ; contains cicatrices of old (tubercular) ulcers ; no recent ulcera- 
tion. Mesenteric glands in places cretaceous. Left external iliac vein, at 
clot; kidneys congested, not lardaceous ; lungs, old scars at apices; palmonarv artery 
1 contains ante-mortem clot ; embolism. 

N J 



■■■ 



1 80 Diseases of the Liver 



Hepatic Abscess 

Children occasionally suffer from multiple abscesses, the result of the 
absorption of some septic material from the region of the portal vein, or from 
some abscess in the immediate neighbourhood. Thus in one case under our 
care multiple abscesses in the liver were evidently secondary to an ulcer in 
the cascal appendix caused by a pin which had been swallowed. In a second 
case there was a large hepatic abscess communicating through the diaphragm 
with an empyema in the right pleural cavity ; and in a case of Dr. Hutton's 
hepatic abscesses were due to the contiguity of the liver with suppurating- 
retro-peritoneal glands. In some cases which have been recorded abscesses 
in the liver were secondary to typhoid ulcers, and in others to the irritation 
of worms which had penetrated into the bile ducts. The symptoms consist 
in enlargement of the liver, extreme tenderness, and intermittent fever. The 
prognosis is bad. If pus is found, it should be evacuated antiseptically. 

Hydatids 

Hydatid.cysts in the liver are not uncommon during later childhood, but 
are decidedly rare before five or six years of age. If the cyst is of any size and 
situated in either lobe so as to come in contact with the abdominal wall, it 
will form a smooth, rounded swelling continuous with the liver, neither pain- 
ful nor tender, elastic to the touch, or actually fluctuating. Diagnosis under 
such circumstances is easy, especially if the tumour is tapped or aspirated, 
the fluid withdrawn being of low specific gravity, non-albuminous, and con- 
taining some of the scolices or pieces of cyst wall. If the cyst occupy the 
posterior part of the right lobe, it may push the diaphragm upwards and dis- 
charge into the lung or pleural cavity ; occasionally the cyst suppurates — in 
this case there are hectic fever, pain, and the symptoms of an abscess. 

Treatme?it. — Aspiration of the contents of the cyst may be sufficient * 
the latter collapses and the hydatid is destroyed. The operation may have 
to be repeated, as the cyst may fill up with serum. If suppuration occurs 
incision is required, and in many cases it is better to open the abdomen r 
secure the cyst to the abdominal wall, and drain the cavity without any 
previous aspiration, even if suppuration has not taken piace. 

Tumours of the Xiiver 

New growths originating in the liver during childhood are among the 
greatest rarities, though cases of carcinoma, sarcoma, adenoma, and cavernous 
tumours have been described. An interesting case of lymphadenoma of the 
liver, the only one which we have met with, was admitted to the Children's 
Hospital, under Dr. Humphreys (now of Torquay), in 1878. 

A boy aged 14 years suffered, for a month before coming under notice, with pain in 
the right hypochondriac region and wasting ; he noticed a swelling in the same region 
about two weeks before admission. When first admitted he was pale and sallow, but not 
jaundiced, the liver was enlarged, the edge reaching nearly to the umbilicus ; there was a 
large bossy swelling situated between the right costal arch and the umbilicus ; the super- 
ficial abdominal veins were enlarged and tortuous. Aspiration of the tumour yielded 



Tumours of the Liver 1 8 1 

nothing but blood. He wasted, there was a hectic temperature (98°-io2°), and the 
peritoneum and right pleura became distended with fluid. He died seven weeks after 
admission, having had symptoms for three months. At the post-mortem the abdominal 
cavity contained much fluid, the right lobe of the liver was much enlarged and contained 
a hemispherical mass, which on section had the appearance and consistence of brain 
tissue; there were some haemorrhages into its substance, and fibrous bands passed through 
it. It was surrounded by a broad zone of compressed liver tissue. There was a mass of 
enlarged glands at the fissure. The right pleura was full of fluid. Microscopically the 
new growth resembled the structure of lymphatic glands. In this case it was not easy to 
decide where the growth commenced, but, as in the analogous case of lymphadenomata 
of the kidney, there is a strong probability that it began in the lymph glands of the fissure 
and grew into and compressed the liver substance. 



1 82 Diseases of the Respiratory Apparatus 



CHAPTER XI 

DISEASES OF THE RESPIRATORY APPARATUS 

The Thorax in Infancy and Childhood. — It is necessary when exa- 
mining the chest of an infant or child for the first time to have it completely 
bare, so that a thorough examination can be made, the infant lying in its cot 
or on its mothers lap ; care must, of course, be taken to have the room suffi- 
ciently warm, as infants readily take cold when a large surface of the skin 
is exposed, and they are very sensitive to draughts. 

The way in which the child breathes should be carefully noticed. There 
may be a ' crowing ' inspiration as in laryngismus, or it may be stridulous,. 
there being an evident obstruction both to filling and also emptying the 
chest. The cough may have a metallic or clanging ring. 

On inspection it will be noticed, prstiy, that an infants chest is deeper 
than an adults, or, in other words, the antero-posterior diameter more nearly 
approaches the transverse, the ratio being 1-2 in an infant, 1-2^ during child- 
hood, and 1-3 or $h in adults ; the horizontal section is thus more circular in 
form during infancy than in later life. Secondly, the angle which the costal 
cartilages make with the sternum is larger in children than in adults, that is, 
the lower part of the thoracic cage is widened out more ; this may be in part 
due to or accentuated by the abdominal viscera occupying a relatively larger- 
space and pressing the diaphragm upwards. This is seen in an exaggerated 
form in children who have enlarged livers and constant gaseous distension 
of the stomach and intestines. Any acquired deformity should be carefully 
noted ; various rickety deformities may be present — one side of the chest may 
be contracted from an old pleurisy or empyema, or the left chest may be 
bulged outwards by an hypertrophied heart or distended pericardium. 

The position of the cardiac impulse should be determined. Note must 
also be made of the frequency and character of the respiratory movements, 
whether deep or shallow, whether one side moves more freely than the other, 
or there is any sinking in of the epigastrium or intercostal spaces and ribs 
during inspiration. It should be borne in mind that mere frequency of 
respirations does not necessarily mean an}- respiratory disease, but may 
be due to rapidity of the hearts action accompanying high fever or cardiac 
feebleness. Note also if there is any paralysis of the diaphragm or inter- 
costals. 

After inspection it is usual to per rus s the chest, placing one finger of the 
left hand against the chest wall and striking it with more or less force 
with the middle finger or forefinger of the right hand, taking care that the 
child lies or sits up straight, for if the body be twisted, so that one side 



Cojigenital Laryngeal Stridor 183 

bulges out more than the other, a fallacious hyper or impaired resonance may 
be produced. All the regions of the chest must be carefully examined in turn. 
Too much stress should not be laid on a slightly impaired resonance, espe- 
cially if the child is crying, unless the result of auscultation corresponds, 
and a subsequent examination confirms the result. A typical ' cracked-pot ' 
sound is readily elicited in an infant on account of the yielding nature of the 
chest walls quite apart from the presence of cavities or any lung lesion : 
Careful note must be made of any spot where there is dullness or impaired 
resonance or hyper-resonance denoting empysema, but bearing in mind 
that at times a ' boxy ' note is elicited over lung in an early stage of pneu- 
monia or acute congestion. It must not be forgotten in examining the 
chest that the diaphragm usually takes a higher position in children than in 
adults, especially when the stomach and intestines are distended with gas. 

In auscultation the ear may be placed directly against the chest wall, or 
(what is much more convenient) a binaural stethoscope with a small chest 
piece may be used. All parts of the chest should be carefully examined, 
noting the character of the breathing, whether the air is entering every 
part of the lungs equally, or whether the air is not entering one part freely 
while other parts are being overworked. Weak breathing may be due to an 
early stage of pneumonia, effusion of fluid, collapse of lung, compression of a 
bronchus, or a pneumo-thorax. 

i Puerile ' or harsh breathing is due to a portion of lung being over- 
worked ; it is never safe to accept it as a sign of a lesion in the lung, as 
at first a student is inclined to do, and, moreover, the breath sounds may 
appear loud and harsh to an ear accustomed only to adults. It is not uncom- 
mon in young children to note on one occasion that the breathing is weak or 
almost absent at one base and loud elsewhere, whereas after a fit of crying, 
or the next day, the weak breathing has completely disappeared ; in these 
cases a bronchus with its branches has been temporarily plugged with 
mucus, which has become displaced by coughing. Bronchial breathing is 
present in consolidation of the lung from pneumonia or tubercular infiltra- 
tion, but it is also present in the majority of cases in effusion of fluid, though 
in this case it is usually weak and distant instead of being intense and blowing. 
Cavernous or amphoric breathing is not often heard, as cavities of any size 
are rare in young children. Among the adventitious sounds, fine crepitation 
is rarely heard in the early stages of pneumonia, the rales being mostly ot 
medium size ; they may be ' consonant ' or ' ringing' in character when con- 
veyed to the ear through solid lung, or subcrepitant and ill defined when the 
secretion is thick and they have to pass through normal lung to reach the 
ear. Vocal resonance, or fremitus, often gives no definite result in girls or 
young children, though when the child is crying violently the increased reso- 
nance of the voice heard over a base or apex may be of diagnostic importance. 
It is needless to add that the physical examination of young children is often 
beset with difficulties on account of their restlessness or fright, and the 
examiner may have his patience often sorely tried, and perhaps may tail to 
obtain a satisfactory examination from this cause. 

Infantile Respiratory Spasm, Congenital laryngeal Stridor. It is 
not uncommon to meet with infants a few weeks old, who from their birth 
have made a peculiar stridulous sound, more especially during inspiration. 



184 Diseases of the Respiratory Apparatus 

In most cases this state of things lasts for some months, perhaps getting 
worse, and it gradually disappears, so that before the middle of the second 
year is reached it has entirely disappeared. It is not dangerous to life, as is 
true laryngismus. This condition has been noted by several writers, includ- 
ing Drs. Gee and D. B. Lees, but the fullest and most recent account has 
been given by Dr. J. Thomson Edin. Med. Journal). The last writer has 
carefully studied five cases, and made laryngeal examinations as far as it was 
possible, but it is rare to be able to get a good view of an infant's vocal 
cords. He describes the stridor as follows : ' inspiration begins with a croak- 
ing noise and ends in a high-pitched crow, which two of the mothers 
described as being just like a hen. ; In some cases there is an indrawing of 
the chest wall during inspiration and a tendency to pigeon breast. The 
laryngeal examinations made by Drs. Thompson and McBride showed the 
epiglottis as far as seen to be normal, though in one case there was a chronic 
pharyngitis. It is clear in most cases the stridulous noise is produced by a 
spasm of the muscles of the larynx, and is apt to be worse when the infant is 
excited, in this respect resembling laryngismus. The etiology is by no 
means clear. It does not seem to be affected by drugs. 

In some few cases we have noted, in addition to a certain amount of noisy 
respiration in infants, there is a tendency to choke when drinking, some of 
the fluid entering the larynx by accident. This condition, though alarming 
to the friends, does not appear to be dangerous, and gradually improves as 
the infant grows older. In all these cases it is wise to examine carefully for 
post-nasal adenoids. 

laryngismus. Spasm of the Glottis. ' Child Crowing- ' 

The term laryngismus is applied to a peculiar form of laiyngo-respiratory 
spasm which occurs almost exclusively in rickety infants. In laryngismus 
there is no lesion of the larynx, or only in a small minority of cases is there a 
laryngeal catarrh ; it is usually a pure neurosis, and it is only for the sake of 
contrasting it with other forms of laryngeal troubles that it is placed in this 
section rather than among the convulsive disorders, to which it more properly 
belongs. 

In by far the majority of cases the symptoms of rickets are present, but 
we must not in all the cases expect to find marked enlargement of the 
ep : physes, especially in infants of a few months old. Sometimes cranio-tabes 
may be detected ; usually there is some beading of the ribs and recession of 
the chest walls during inspiration. 

The characteristic feature of the attack is a sudden 'holding of the 
breath ' for a few seconds ; then the glottis is burst open, the air rushing in 
with a stridulous sound or in a series of short ' chinks,' but in many cases 
there is no abnormal sound, the attack consisting entirely of holding the 
breath. The seizure closely resembles, only in an exaggerated form, the 
* catch in the breath,' which takes place as a preliminary to a good fit of 
crying, or, as Gay points out, of rage or bad temper. The condition seems 
to be as if the expiratory respiratory centre discharges for a few seconds an 
excessive quantity of nerve force, producing a spasm of the glottis and of the 
muscles of expiration, while the more powerful inspiratory centre, as it is more 






Laryngism us I o 5 

and more stimulated by the increasing venosity of the blood, strives, as it 
were, for mastery, and at length, when it succeeds, the glottis is burst open, 
.and air rushes in through the narrow chink. In a severe attack, not only is 
the glottis closed by the adductors of the cords, but the epiglottis may be 
felt by the finger to be spasmodically applied to the superior aperture of the 
larynx, and the respiratory muscles are in a state of spasm. 

Semon and Horsley have shown that the expiratory respiration centre is 
situated in the monkey in the cortex, 'just posterior to the lower end of the 
praecentral sulcus at the base of the third frontal convolution.' Stimulation 
■of this region produces adduction of the vocal cords, and if the excitation be 
powerful enough, spasm of the muscles of the face, neck, and upper limbs. 
The same observers failed to discover any inspiratory cortex centre, but 
found that excitation of the accessory nucleus in the medulla oblongata 
evoked abduction of the cords. In rickets the nerve centres are in an 
unstable condition, and liable to liberate nerve force on the slightest provo- 
cation. In some cases many of the cortex centres discharge, and a general 
convulsion is produced ; in other cases it may be, at first at any rate, the 
•expiratory respiration centre only, and a spasm of the glottis is produced. . 

The exciting causes are probably many. The commonest is some emo- 
tional disturbance : a fit of crying or of anger may quickly pass into an 
attack ; fright or a sudden start may bring one on. The act of swallowing 
seems also sometimes to give rise to an attack. Dentition, irritation of the 
mucous membrane of the pharynx and larynx, nasal adenoids, constipation, 
may perhaps act as exciting causes. In an infant we saw with Dr. Lawton, 
■of Eccles, the attacks were apparently worse during the time it was suffering 
from some aphthous ulcers on the soft palate. We have also seen cases 
which were worse during an attack of bronchial catarrh. We are not 
inclined to attach much importance to an enlarged thymus, swollen bron- 
chial glands or cranio-tabes as exciting causes. 

Symptoms. — In the milder cases, which are the most common, the child's 
inspiratory movements are accompanied by a slight ' crowing sound,' which 
■does not appear to distress it, and which passes oft" during sleep Some- 
times the crowing will last for days, and pass off again for some time. In 
some few cases the stridor is present during sleep as well as during the time 
the child is awake. In the most severe cases the attacks come on at frequent 
intervals, and are distressing in the extreme ; without warning, the infant is 
seen to screw up its face as if for a crying fit, it holds its breath, no air enters, 
and the respiratory muscles are rigid and motionless, the veins on the face 
and scalp become distended with venous blood, the face and lips become 
blue, or of a dusky tint ; then after ten or more seconds the obstruction to 
the air entering the lungs is overcome, and air rushes into the now open 
glottis. In some cases we have noted that while at first the respiratory 
muscles are quite motionless, in others, after the obstruction has lasted some 
seconds, the diaphragm begins to work spasmodically, and will often succeed 
in forcing the glottis, so that for a lew seconds air is admitted at short in- 
tervals into the chest ; then for a time the attack is over, but may be shortly 
followed by another. 

These seizures, especially the more severe ones, are accompanied by 
clonic spasms of the limbs ; sometimes we have seen in these attacks the 



1 86 Diseases of the Respiratory Apparatus 

infant throw his hands up like a drowning man, and then, after the laryngear 
spasm is over, the nerve discharge passes into the limbs, and the hands, 
become set, as in tetany, with the thumbs turned in, and the feet in a position 
of equino-varus. 

These attacks may come on at all times of the day or night, and on very 
slight provocation. We have already referred to the most common exciting- 
causes ; the most important, perhaps, is some emotional disturbance. One 
of these seizures, as we have already pointed out, is very much like what 
takes place in the early stages of a fit of crying ; the facial muscles are con- 
tracted, the mouth is open, the breath is held, the air enters the chest spas- 
modically by the contraction of the diaphragm. Herbert Spencer remarks- 
that an ' overflow of nerve force, undirected by any motive, will manifestly 
take the most habitual routes ; and if these do not suffice, will next overflow 
into the less habitual ones. : We can easily understand on this principle that 
a discharge of nerve force from unstable nervous centres may take the routes 
which in infants produces a good cry, and may overflow into the muscles of 
the extremities, producing a spasmodic condition, i.e. 'tetany. 5 

One point we must not forget to emphasise, and that is, that many of the 
most severe seizures are not accompanied, or rather followed, by a definite 
crowing sound. It is really the less severe ones in which the crowing in- 
spiration is best marked ; the danger necessarily depends more upon the 
length of time during which the breath is forcibly held, than upon the manner 
in which the air again enters. In many of the worst cases it is admitted 
spasmodically in sobs, and not in a long-drawn crow. 

Children who suffer from laryngismus are not only rickety, but are nearly- 
always dyspeptic. There is often a difficulty in digesting cow's milk, the 
stools contain much undigested curd, and there is chronic distension of the 
bowels. They are not infrequently well nourished, as far as fat goes, but 
their muscles are poorly developed. It is unnecessary to say that it is 
artificially fed infants who are the chief sufferers from laryngismus. The 
following case illustrates some of the points we have referred to : 

Laryngismus; Recovery. — S. H. , aged 10 months ; admitted February 28. Mother states 
he has never been strong, has had a ' croupy cough' since 14 days old. For the last few- 
weeks has had many choking fits, sometimes as many as twenty in one day. Weight, 
9 lb. 14 oz. He is small for his age and cannot sit up ; he has no teeth, fontanelles 
widely open and tense ; no cranio-tabes ; some recession of the chest walls during inspira- 
tion ; no marked beading of the ribs. When disturbed he makes a crowing sound with 
inspiration. During this time there is marked indrawing of the chest wall, lasting for a 
few moments. At other times the breath is held tightly for a few seconds till he becomes 
blue in the face. He was ordered milk, half a pint, and whey, one pint and a half daily, 
and some rhubarb and soda. March 2. — Has had many attacks of ' crowing,' and 
between the attacks there seems to be more or less constant spasm. March 4. — Ordered 
tr. belladonnas imv, pot. bromidi gr. ijss, om. 4tis hor. He had six attacks yesterday ; 
no general convulsions. From this date he began to improve, the attacks becoming less.. 
He went home on March 21 (weight, 10 lb. 1 oz.), having had no attacks for ten days or 
more. 

Spasm of the glottis is sometimes the cause of death in cases where the 
obstruction is not complete, as in the following case. A boy of 1 year old 
had difficulty in breathing from birth, was seized with a bad attack, and was 
admitted to hospital ; there was undoubted obstruction to inspiration and. 



Laryngismus 



1 87' 



much recession of the chest walls, necessitating tracheotomy, which was 
followed by much relief. Death followed five hours later without apparent 
cause. At the post-morte?n there were no signs of rickets ; there was slight 
congestion of the larynx and the thymus gland ; all the other organs were 
healthy. Sudden death from spasm of the glottis occasionally occurs in 
cases of tuberculosis with enlarged and caseous mediastinal glands. 
Diag?iosis. — The following table gives the chief points : 



Laryngismus : Spasm of the 
Glottis. 

Occurs in rickety children 
under 18 months of age. 

No fever, and no coryza or 
laryngeal catarrh. 

Occurs at any period of the 
24 hours, and often many 
times. 

No cough, inspirations are 
stridulous. 

Contractions of the limbs, 
or general convulsions, 
not uncommon. 

The attack lasts a few se- 
conds, and frequently re- 
curs. 

Occasionally fatal. 



Spasmodic Laryngitis 
[False Croup). 

Rarely occurs under 2 years 
of age, commonest 2-7 
years. 

Slight fever, mostly coryza 
and laryngeal catarrh. 

The attack occurs at night. 



Metallic cough, stridulous 
respiration, variable dys- 
pnoea. 

Convulsions rare. 



Attack parses off in the 
course of an hour or two. 



Membranous Croup. 



Occurs at all 
childhood. 



iges during 



Rarely fatal. 



Variable amount of fever„ 
and perhaps some diph- 
theria of the fauces. 

Mostly worse at night. 



Metallic cough, stridulous. 

respiration, progressive 

dyspnoea. 
Convulsions rare. 



Becomes steadily worse, 
though variations occur 
in its progress. 

Very often fatal. 



Prognosis. — The great majority of infants who suffer from ' child crowing " 
recover ; the prognosis, however, must always be a guarded one, and as long 
as there is any tendency to spasm of the glottis the child cannot be regarded 
as out of danger. A ' crowing' child may at any time have general convul- 
sions and die in a few moments. Improvement in the child's general condi- 
tion, and especially of its digestive powers, quickly leads to an improvement in 
the ' crowing ;' this we have noticed in several cases which rapidly improved 
under the careful feeding and attention in the hospital, but which quickly re- 
lapsed again when they were discharged. An attack of bronchitis or broncho- 
pneumonia is very likely to prove fatal in a child subject to laryngismus. 

Treatment. — During the spasmodic stage when the breath is being held,, 
ever}- effort must be directed towards exciting reflexly the inspiratory respi- 
ratory centre. A sponge well wetted with cold water may be dashed into 
the face ; patting on the back, or a vigorous shake, will sometimes lie suc- 
cessful. It is useful to have a hand fan within reach, and use it vigorously 
during an attack to fan the face. 

We have found that hooking back the epiglottis with the forefinger has 
been followed by an inspiration. In one of our own cases a child who was 
subject to these attacks had a severe seizure while under chloroform for the 
removal of post-nasal adenoids, and his life was only saved by the ra 
performance of tracheotomy. In such cases a catheter passed into the Ian nx 
would suffice to insure the entry of a small quantity ol air. 



1 88 Diseases of the Respiratory Apparatus 

The most useful medicines for temporary use to keep the attacks in 
check are chloral, bromide, and minute doses of morphia. We should only 
give these drugs in the severe forms of spasms in order to soothe or render 
less irritable the unstable state of the nervous system. Five grains of 
bromide with two and a half of chloral may be given to an infant of 6 
months, and repeated every six hours. A drop of liq. morphias maybe given 
every six hours, its effect being carefully watched. 

The most important part of the treatment is with regard to the diet and 
surroundings of the child. It is of the greatest importance that it should 
get fresh air. A steam tent and hot close room is the worst possible place 
for an infant suffering from laryngismus. A change away to the seaside often 
works wonders, by improving the infant's digestive powers and general health. 
A food or foods must be found and given in quantities which the child can 
•digest. It will probably be found that the child is taking more milk than it 
can digest, and is passing large pasty stools. The amount of milk must be 
diminished. Peptonised foods, cream mixtures, thin oatmeal gruel, beef juice, 
beef tea with vegetables, all have their value in these cases, if given in 
suitable quantities according to the child's digestive powers. Medicines 
which assist the digestion and regulate the bowels are often necessary ; 
extract of malt, rhubarb and soda, acids and pepsine, and, above all, cod liver 
oil, when it can be taken and digested. Constipation must be removed. If 
a child has laryngismus and post-nasal adenoids, is it safe to operate? We 
have several times operated with great advantage, but it is necessary to be 
on the look-out for spasm of the glottis. Intubation may be performed or a 
catheter passed into the trachea, if necessary, and artificial respiration 
performed. 



Spasmodic Laryngitis, Catarrhal Spasm. False Croup 

This affection differs from the last described in that it consists in a sudden 
but not complete stenosis of the glottis associated with a laryngeal or pharyn- 
geal catarrh. A child, usually above 2 or 3 years of age, goes to bed 
apparently well, or there may be a slight hoarseness or cold in the head ; 
after a few hours' sleep he is suddenly awakened with alarming symptoms of 
laryngeal obstruction. There is a loud metallic cough, stridulous respiration 
more especially with inspiration, the dyspnoea and distress are very great, 
there is recession of the chest walls, and all the accessory muscles are called 
into requisition. The orthopncea and distress are so great that death seems 
imminent. In the course of a few minutes, probably before the arrival of 
medical assistance, which is hastily summoned, the laryngeal obstruction 
has ceased, and the child, tired out by its unwonted exertions, falls into a 
quiet sleep. The symptoms of a catarrh or tracheitis persist for some days 
perhaps with some clanging cough and more or less pronounced attacks of 
dyspnoea at night. Children who thus suffer are extremely liable to a re- 
currence whenever they take cold, and it is not uncommon for mothers to say 
that their child is very subject to ' croup.' Though these attacks are alarming, 
they are rarely fatal, thus contrasting with laryngismus ; but it must be re- 
membered that the latter is frequently associated with general convulsions, 
and, moreover, occurs at an age when spasm of the glottis is necessarily 



Catarrhal Laryngitis 189 

dangerous if severe on account of the weakness of the respiratory muscles 
and want of rigidity in the chest walls. Children who have chronically 
enlarged tonsils or nasal adenoids are exceedingly apt to suffer from 
spasmodic laryngitis. 

These attacks of spasmodic croup differ very much in severity ; in some 
cases they are very mild, but on account of their occurring at night, 
and the dread in which all forms of croup are held, they are exceedingly 
apt to alarm the friends. Several children in the same family may suffer, 
and there is often a history of these attacks to be obtained in other members 
of the family. 

Treatment. — Great care should be exercised to protect children subject 
to such attacks from cold. A damp house or a damp situation should be 
avoided, and exposure to the cold east winds of spring should be carefully 
guarded against. Great benefit is usually derived from residence at the sea- 
side. Cold sponging with tepid salt and water every morning on getting up 
will greatly assist in keeping the child free from attacks. Warm woollen 
clothing should be worn next to the skin, and care taken that the legs and 
neck are well protected. Enlarged tonsils or adenoids must be removed. 
During the attack most relief is given by applying hot sponges to the throat 
and by administering an emetic of ipecacuanha powder (5 to 10 grains) or a 
teaspoonful or two of ipecacuanha wine. As the child gets older he becomes 
less and less liable to these attacks, which cease altogether before puberty is 
reached. 

Catarrhal Laryngitis 

Children of all ages are liable to suffer from a catarrh of the larynx and 
trachea, though it is perhaps most common and is certainly most dangerous 
during the first two or three years of life. These attacks differ somewhat from 
those of spasmodic croup just described, inasmuch as there maybe no violent 
exacerbation at night, yet in many cases all the symptoms are apt to be worse 
towards evening. In both cases there is laryngeal catarrh and laryngeal 
spasm, and they differ only in degree ; in the spasmodic variety there is usually 
little catarrh, but severe attacks of spasm of the glottis ; in the catarrhal 
variety the catarrh is much more severe, and perhaps the spasm is not well 
marked, but all these cases are apt to become much worse at night, apparentlv 
from the presence of more or less spasm. They are mostly the result of cold, 
exposure to cold winds or a chill, and they may be associated with measles, 
either belonging to the premonitory symptoms or following the disappearance 
of the rash. The attacks are preceded for the most part by coryza, feverish - 
ness and cough, the first suspicious symptom being the changed character of 
the cough, which is at first hard or hoarse, and then assumes the characteristic 
' croupy ' or 'brassy' character, which announces that there is some stenosis 
of the larynx. An examination of the fauces will probably show enlarged 
and congested tonsils with excessive secretion, and if the epiglottis can he 
seen, the mucous membrane will be found to be o\ a pinker colour than usual : 
but it is rarely possible to get a view of the larynx by means of the laryngo- 
scope. As the symptoms become more marked, the air is heard to enter the 
larynx with a hissing sound, there is dyspnoea, the ale nasi work, the chest 
walls fall in during inspiration, and there is often much distress. In some 



190 Diseases of the Respiratory Apparatus 

•cases the child has to be propped up in bed, and pays no heed to its toys, its 
■whole attention being taken up in its efforts to breathe. The fever is 
variable, rarely high, usually ioo° to 101 ; the pulse is quick and hard. In 
most cases the symptoms are milder than those just described, there being 
only a croupy cough and some acceleration of breathing. In the later 
stages the secretion becomes freer and muco-purulent. On the other hand, 
the case may become so urgent that intubation or tracheotomy is required 
to stave off impending death, though usually the effects of treatment render 
this unnecessary. Cases of simple catarrhal laryngitis in children rarely 
present the picture of stenosis of the larynx which is seen in the membranous 
variety; there is probably the ' croupy ' cough and frequent breathing, but 
between whiles, especially after a fit of coughing, the child is comparatively 
comfortable, and falls into an easy sleep. The prognosis depends upon the 
diagnosis ; if the case is one of catarrhal laryngitis and the child is over 
2 or 3 years of age, there is strong probability that it will recover. The 
younger the child, the greater is the danger. 

Treat7iient. — The first appearance of 'croupy' symptoms should never be 
neglected ; the hard metallic cough, when once heard, should be the signal 
for placing the child in a warm room, where the temperature is maintained 
at 6o° or 65 both day and night, giving at the same time fluid food or sops, 
-demulcent drinks, and medicines which promote diaphoresis. If the symp- 
toms become more pronounced, the child must be confined to its cot, and a 
tent rigged over it by means of sheets stretched over cords or a clothes 
horse, so as to protect the patient from draughts, and a moist atmosphere 
must be secured by the aid of the steam kettle. Some carbolic acid or tr. 
benzoin co. may be placed in the kettle. The temperature inside the tent 
should be maintained at about 70 , and steam from a kettle allowed to play 
freely into it, so as to render the air thoroughly warm and moist. The usual 
tendency of the friends of the patient is to overdo the steam and maintain 
too high a temperature, so that it is not uncommon to find the patient almost 
parboiled. 

During the early stages of laryngitis, when there is much swelling of the 
mucous membrane of the larynx, with little secretion, the steam gives more 
■or less, at least temporary, relief. This is most marked in the cases of hospital 
patients who have been much exposed before being admitted ; in these cases 
the amount of relief given by the steam tent is often an important element in 
the diagnosis of catarrhal versus membranous croup. A steam kettle should 
be heated by means of a spirit lamp rather than by gas or by placing it 
on the fire, as in the latter case the patient's cot has to be placed close to the 
fire. The products of the combustion of gas are objectionable, especially in 
.a small room. Local applications applied over the larynx in the form of 
hot sponges or spongio-piline wrung out of hot water are often of much 
service. The sponges should be taken out of the hot water and squeezed 
by wringing in a piece of flannel and used continuously ; but if this exhausts 
the child too much, a piece of spongio-piline may be secured in situ by tapes 
and renewed every half-hour. An emetic in this stage is often of much 
value in relieving the breathing and producing free expectoration, ipeca- 
cuanha powder answering very well. Five grains may be given in syrup of 
•orange peel every ten minutes till vomiting is produced. Sulphate of copper 



Catarrhal Laryngitis 191 

'in gr. \ to gr. \ doses, repeated in a few minutes, will generally produce 
vomiting. It is useless to repeat emetics if they fail to give relief. It need 
hardly be said that it is wrong to give emetics in the later stages, when the 
breathing has become laboured and the lips blue or pallid ; to give emetics 
under these circumstances is to risk failure and to waste invaluable time. Of 
medicines, antimony unquestionably holds the first place, and in sthenic cases 
should be given with a free hand, though as an emetic it is too slow and 
nauseating. Either the wine or tartar emetic may be given, in combination 
with citrate of potash or acetate of ammonia. (F. 23.) Tartar emetic may 
be given in powder or in ' tabloids,' gr. B ^ to gr. T ^ every two or three hours 
according to age. Both ipecacuanha and aconite in small and repeated 
doses are useful. 

The only food admissible is milk diluted with barley water or soda water, 
preferably given warm to assist in producing perspiration. In most cases of 
catarrhal laryngitis relief of the most urgent symptoms follows this line of 
treatment, though probably for several days many of the symptoms will 
remain, with exacerbations at night ; in such cases the antimony may be 
pushed, nauseating doses being given. 

The question as to whether intubation or tracheotomy should be per- 
formed is always a difficult one, inasmuch as in many cases the most urgent 
symptoms will disappear under the influence of treatment, and the operation, 
•even in the most skilful hands, adds another element of danger to the case. 
It is impossible to lay down any rule for the performance of the operation, 
•or to select any one symptom which is to be taken as the signal. Dyspnoea 
and recession of the chest wall do not necessarily indicate any immediate 
danger, and most of us will have seen cases in which there has been indrawing 
-of the epigastrium and ribs recover without operation. If, however, the case 
passes into a later stage in which the voice almost disappears, the respiration 
becomes laboured, all the respiratory muscles joining in the attempt to draw 
in air and expel it from the chest, while the distress and restlessness are on the 
increase, it is then quite certain that the time has come for affording relief. 
If there is marked pallor of the face, coma, delirium, or other symptom of 
toxaemia, there is not a moment to lose. 

The difficulty is in large measure due to the uncertainty of our diagnosis. 
If we are sure that we are dealing with a case of catarrh pure and simple, 
•even though the symptoms of obstruction are threatening we can afford to 
wait, and give our treatment a fair trial before proceeding to operate, know- 
ing that much of the obstruction is due to spasm, which may at any time 
suddenly subside. Death from asphyxia must be very rare in a case of 
catarrhal laryngitis over two or three years of age. But it is comparatively 
seldom that we can make a certain diagnosis — at first, at any rate— between 
catarrhal and membranous laryngitis, as it may be only after tracheotomy 
has been performed, and sometimes even a day or two later, that membrane 
is coughed up. It is often not easy to decide as to the time for operative 
interference, but in a case where there was a history ot the child having 
suffered before from ' croup,' and where the breathing tended to v ^et worse 
at night and afterwards improved for a while at least, we should delay 
operative interference as long as possible, in the hope that improvement 
might take place. On the other hand, in a case that Steadily got worse with- 



192 Diseases of tJie Respiratory Apparatus 

out any intermissions, we should certainly advise operative interference in 
good time, as there would be little chance of a successful issue to the case 
unless the obstruction were relieved. 



Membranous laryngitis 

Is membranous laryngitis always diphtheritic ? Can there be diphtheria 
of the larynx without any tough membrane being present? In the great 
majority of cases there can be no doubt that if membrane be present the 
case is one of diphtheria. It must also be said that in the great majority of 
cases, if there is no membrane, there is no diphtheria. But in the present 
state of our knowledge it is not wise to take up a dogmatic position, except 
in so far as to view every case of laryngitis, whether we find membrane or 
not, with the greatest suspicion, as all such cases may turn out in the end 
to be diphtheria, and we may regret when too late that we did not at first 
treat them as such. We must leave the discussion of the relation of 
membranous exudations to diphtheria to a later chapter {see Diphtheria). 

Symptoms. — The initial symptoms of membranous croup, whether diph- 
theritic or not, are practically identical, inasmuch as they are those of stenosis 
of the larynx. When the larynx is the primary seat of the attack the symptoms 
are those of catarrh, with restlessness, feverishness, and brassy cough. In 
the course of a day or two, sometimes sooner, there is more or less loss of 
voice and the cough has a peculiar ringing or metallic character, which is 
very characteristic. 

It now becomes evident that there is some obstruction in the larynx, as 
the air enters the trachea with a hissing or stridulous sound, and the child is 
constantly endeavouring to cough something up and clutches at its neck as 
if to remove some obstruction. The tonsils are usually swollen, the fauces 
reddened, and perhaps the seat of false membrane. There is marked rest- 
lessness ; the child wants to be nursed, then put back again into its cot, per- 
haps get a few minutes' sleep, waking up with a hoarse cough and difficulty 
of breathing. The voice now is nearly lost, the child speaking in a whisper 
and making itself understood with difficulty. There is marked dyspnoea, 
which tends to increase as the disease progresses ; the alae nasi dilate, the extra 
inspiratory muscles are called into action, and the epigastrium and inferior 
lateral region of the chest, the intercostal spaces, and supra-sternal fossa are 
drawn in during inspiration. The expiratory efforts are laboured, so that 
the abdominal muscles act with some force, and the air escapes through the 
larynx with a noisy sound. So laboured and noisy is the breathing that it 
can be heard some distance off. While the child goes from bad to worse, 
there are usually more or less marked exacerbations ; the child is easier 
after a fit of coughing, during which mucus or perhaps some membrane is 
actually dislodged. All the symptoms are apt to be worse at night. 

If no relief is obtained the symptoms of toxaemia begin to present them- 
selves. There is a marked pallor or lividity about the lips and face ; per- 
spirations break out on the forehead ; the restlessness is often intense ; the 
child is perhaps drowsy and delirious, perhaps attempting to get out of bed ; 
presently complete insensibility comes on, the pupils dilate, the attempts at 
respiration become more and more feeble, and death quickly ensues. The 



Membranous Laryngitis 193 

temperature is usually raised a degree or two in the earlier stages, but may 
be subnormal as the blood becomes more venous. An examination of the 
chest does not always yield positive results as to the state of the lungs. The 
whistling or stridulous sound produced in the larynx is heard all over the 
chest, masking the vesicular breath sounds, and making it difficult to 
diagnose the condition of the lung. The supraclavicular regions in front are 
usually unduly resonant from the presence of emphysema, while at the bases 
posteriorly the resonance is mostly impaired on account of the lung being 
collapsed, or air entering it very imperfectly. The diagnosis of pneumonia 
is difficult in the absence of impaired resonance, as the typical signs maybe 
wanting on account of the small supply of air entering the chest : moreover, 
the pneumonic consolidation may be masked by emphysema. It is difficult 
to diagnose the presence of membrane in the trachea and bronchi ; but if 
.after tracheotomy has been performed the breathing is still laboured with 
indrawing of the chest walls, there will be strong reason to suspect that the 
bronchi are obstructed by membrane. 

When the larynx is affected secondarily the symptoms are frequently 
much less marked, more especially if the membrane only spreads to the 
larynx after it has existed for some days in the pharynx or nasal mucous 
membrane. In this case the weakness and depression which exist before 
the laryngeal complication supervenes mask the symptoms of laryngeal 
stenosis. There is usually much less dyspnoea and distress than when a 
liealthy child is suddenly attacked. When the primary seat of the membrane 
is in the bronchi and it ascends to the larynx, the symptoms closely 
resemble purulent bronchitis, as in the following case : 

Ascending Diphtheritic Croup. — Thomas Mac, 7 years. Boy was quite well till 
February 8. He complained of his throat, and became hoarse ; he had also a cough. 
On February 8 he came to the Throat Hospital, where examination showed the cords and 
larynx were healthy. February 11. — Seen by Mr. Westmacott at the Children's Dispensary ; 
hoarseness and signs of bronchitis were noted, and he was sent to hospital. On admission 
•he is a well-nourished boy, some dyspnoea, but a good colour. There is recession of the 
lower part of the chest. Pulse, ioo° ; respiration, 28 ; temperature, qq'8 ; chest 
resonant. Rhonchi heard all over chest. No enlarged glands to be felt ; some diffuse 
redness of fauces ; no membrane. Steam tent ; sick twice after pulv. ipecac, gr. xv. 
February 12. — There is more marked recession than yesterday ; spits some purulent 
sputa ; rales heard in chest. At noon, intubation by Mr. Lea, coughed up much stringy 
mucus. Temperature 98°-ioi° ; no membrane. February 13. — Respiration easy ; tube 
remains. Temperature 101 . February 15. — Tube removed ; breathes easily, but coughs 
up a good deal of greenish pus. Urine contains a trace of albumen. February 16. — 
Respiration easy ; no recession ; urine a large amount of albumen. Intubation at 10.45 '• 
coughed tube up in a few minutes. Intubation again at 1 P.M. ; much muco-pus coughed 
up. February 17. — Child much worse; great pallor. Respiration 32°. Urine scanty ; 
large amount of albumen; weak pulse, low tension. February iS. — Tracheotomy this 
morning, dyspnoea increasing ; no membrane seen. Child died of asthenia early morning. 

Post-mortem. — Thin membrane extending down the trachea and bronchi to the 
smallest bronchi in the lungs ; much mucus present. Some membrane on the epiglottis 
and larynx ; none on the fauces or nares. 

Albuminuria exists in a large number of cases in the early stages, in 
nearly all in the latter stages ; the urine maybe highly albuminous and scanty. 
•Occasionally there may be suppression of urine and uraemic symptoms. 

Diagnosis* — The diagnosis of stenosis of the larynx is not difficult, nor is 








194 Diseases of the Respiratory Apparatus 

it likely to be confounded with bronchitis or broncho-pneumonia where the 
obstruction resides in the bronchial tubes, or where there is extensive con- 
solidation of the lung. In laryngeal stenosis the air rushes through the 
larynx, giving rise to a crowing or stridulous sound, especially during inspira- 
tion, but there is obstruction to the expiration also ; the respiratory move- 
ments are laboured, as if to overcome the obstruction, and with this there is 
marked recession or sucking in of the chest walls during inspiration. There 
i^ loss or great impairment of voice. In pneumonia or bronchial obstruc- 
tion, the dyspnoea may be great and the respirations frequent, with much 
in drawing of the chest wall, but there is no stridor or loss of voice. The 
diagnosis of obstruction of the bronchial tubes, in addition to stenosis of the 
larynx, as in those cases where the membrane has spread downwards or 
where there is an accumulation of mucus below the larynx, is difficult and 
uncertain ; but in all such cases the dyspnoea will be great, and tracheotomy 
urgently required, and the presence of obstructed bronchi would not contra- 
indicate operation, as an opening in the trachea Mould favour the coughing 
up of the obstructing material. 

The differential diagnosis of catarrhal, membranous, and diphtheritic croup 
is generally a matter of great difficulty, and until the case has remained under 
observation for some hours or days often impossible. Even after tracheo- 
tomy has been performed, the nature of the case may still be doubtful, inas- 
much as thick fibrinous mucus may be coughed up with no distinct mem- 
brane, and recovery may take place without the diagnosis having been deter- 
mined. The question of diphtheria or not diphtheria is one of the greatest 
importance, but unfortunately there is not much that can be said with 
certainty. It is easy to say that in diphtheritic croup there is asthenia, 
while in membranous laryngitis the attack is sthenic in nature. But, as a 
matter of fact, it occurs in practice that if the primary seat of the diphtheria 
is the larynx, the first and only symptoms are those of stenosis of the larynx, 
and the pallor and depression and asthenia which result are due to the 
toxaemia produced by want of oxygen, rather than by the working of the 
diphtheritic poison. It is for this reason that the symptoms of membranous 
formations are practically the same whether produced by diphtheria or not. 
If, however, the larynx is affected after the existence for some days of 
diphtheria of the fauces, the symptoms are necessarily modified. The 
diagnosis of diphtheria when primarily situated in the larynx has often to be 
made less from the symptoms of the patient than from his surroundings. 

If diphtheria is epidemic at the time, or if the fauces are covered with 
membrane, or there is albumen present in the urine, the case is almost cer- 
tainly diphtheritic. The discovery of Loeffler's D-bacillus in the secretions 
would place the diagnosis beyond doubt. 

Stenosis of the larynx may be caused in other ways than by the exudation 
of membrane ; the larynx may be compressed by an abscess situated pos- 
teriorly between the larynx and oesophagus, or even laterally ; in this case 
there will be difficulty of swallowing as well as dyspnoea. The trachea may 
be compressed below the larynx by an enlarged thyroid or new growth, but 
the history of the case as well as the local enlargement would distinguish 
between the two. In infants and young children spasm of the glottis will in 
rare cases simulate membranous laryngitis, as in the case given (p. 186). 



Membranous Laryngitis 195 

The diagnosis may be difficult, but the absence of fever would point to 
spasm ; it is rare, however, for any spasmodic affection to come on gradually 
and progress from bad to worse, as is the case with diphtheritic laryngitis. 
In the following two cases, pressure by abscesses on the trachea gave rise 
to dyspnoea ; in one tracheotomy was performed without relief. 

Tubercular Abscess of the Thymus; Pressure on the Trachea; Tracheotomy. — 
Margaret S. , aged 20 months ; admitted November 24, 1892. Mother states she has been 
weakly from birth and subject to bronchitis. Five days ago she began to cough and 
breathe with difficulty. Sweats a good deal, and cannot lie down ; her lips are blue at 
times. 

On admission the child was cyanosed and there was much orthopnoea ; she was given 
three teaspoonfuls of vin. ipecac, in divided doses, but she was not sick. A few hours 
after tracheotomy was performed by Mr. Westmacott, but it failed to relieve the breathing, 
and she died two hours after. 

Post-mortem. — On removing the sternum an enlarged thymus was noted, extending 
from the upper border of the sternum to the bifurcation of the trachea, and lying in con- 
tact with the trachea, and evidently compressing it. Some caseous lymphatic glands 
were adherent to the mass. On section it was found to contain a large abscess cavity 
filled with thick pus. There were some miliary tubercles and broncho-pneumonia in both 
lungs. 

Caries of Cervical Spine ; Abscess compressing CEsophagzis and Trachea. — Richard L. , 
aged 3 years ; admitted February 19, 1894. Mother states for the last fortnight he has 
had a barking cough and wheezing ; he gets feverish and restless at night. On examination 
it was noted he had a harsh metallic cough and husky voice ; prolonged expiration and 
rhonchus all over the chest. March 19. — For the last week the breathing has been much 
worse, noisy, and markedly stridulous ; the cough metallic, and some recession of the 
chest. April 11. — Breathes with a croupy sound ; has attacks of difficult breathing at 
night ; gets blue and distressed. Air enters the chest with a long-drawn sibilant sound, 
is held, and then slowly goes out. Resonance is boxy over the sternum. Face puffy ; 
no enlarged veins. May 14. — Lips and fingers somewhat cyanosed. Sits up if awake, 
but when asleep lies down, though always raised more or less on pillows. Swallows 
solids and liquids fairly well. July 10. — Temperature been irregular since last note; 
varies 97 to ioo°. Breathing has improved of late ; there is a tendency to choke when 
he feeds. September 11.— All laryngeal symptoms have disappeared. Chokes when he 
feeds ; no post-pharyngeal abscess ; no pain in the neck, but he cannot hold his head up, 
and the last two cervical vertebras are very prominent ; he cries with pain if his head is 
rotated. Temperature 98 to 101 . October 13. — Much worse ; for some time past has 
been wasting ; hectic temperature ; had a bad attack of dyspnoea early this morning ; 
much vomiting, pus running from nose and mouth. Death October 23. 

Post-mortem. — Mediastinal glands enlarged, but not caseous ; a small cicatrix at the 
apex of left lung; bronchitis, but not tubercle. In upper part of the posterior medias- 
tinum, and behind the oesophagus is an abscess cavity holding about ,;ij ; it has com- 
pressed the oesophagus and opened into it. Posterior wall of abscess cavity formed by 
spinal meninges in position of seventh cervical and upper three dorsal, the bodies having 
completely disappeared. 

Pathological Anatomy. — The post-mortem appearances found in those 
who have died of membranous or diphtheritic croup differ according to the 
immediate cause of death. In the majority of cases this is due to the forma- 
tion of membrane below the tracheotomy wound and to the lungs becoming 
choked or collapsed. In such cases membrane may be found beginning 
at the epiglottis and extending downwards to the smallest bronchi. As a 
rule the membrane is tough and firmly adherent to the epiglottis and larynx. 
being separated with difficulty, while lower down the membrane is far less 

Q j 



Hi. I 



196 Diseases of the Respiratory Apparatus 

tough and is much more easily detached ; the bronchi usually contain semi- 
purulent fluid, and the bases of the lungs are usually pneumonic or collapsed 
while the apices are emphysematous. In some cases death results from 
asthenia or from septic poisoning, the result of the diphtheritic infection ; in 
such cases the trachea and bronchi may be free from secretion. It is ex- 
ceedingly rare to find at the post-mortem that the membrane is confined to 
the larynx in those cases where tracheotomy has been performed. 

Treat77icnt. — Every case of laryngitis occurring in a child should be at 
once isolated, as what may appear in the early stages to be a mild case of 
catarrhal laryngitis may in the end prove to be diphtheritic. There are mild 
attacks of diphtheria of the larynx, just as there are mild cases of diphtheria 
of the tonsils and fauces. In the early stages the secretion coughed up may 
be muco-purulent only, and later, either before or after tracheotomy or in- 
tubation has been performed, the secretion may be membranous. 

Much that has been said under the head of treatment in catarrhal laryn- 
gitis will apply to the treatment of diphtheritic laryngitis. A steam tent 
should be provided, and warmth and heat should be applied externally to 
the larynx, though any blistering or abrasion of the skin must be carefully 
avoided. If the case is certainly one of diphtheria. we doubt the value of 
either emetics or expectorants. If there is membrane in the larynx there is 
small chance of its being loosened or detached by these means. But, assum- 
ing the case is seen in an early stage, no harm can be done by an emetic of 
ipecacuanha ; Dr. W. P. Xorthrup recommends the yellow sulphate of 
mercury in 5-grain doses. Emetics in the later stage are useless and 
harmful. We must chiefly rely on the application of steam from a steam- 
spray apparatus charged with some antiseptic, and, above all, in relieving 
the stenosis of the larynx by intubation or tracheotomy. The most useful 
antiseptic is bichloride of mercury; carbolic acid, thymol, and oil of pepper- 
mint are also useful. Calomel fumigation has been used with some success in 
America, and is certainly worth a trial. Dr. Xorthrup recommends that a tent 
be rigged up over the cot by means of sheets, made fairly air-tight and of 
about 50 "cubic feet capacity. 15 grains of calomel are volatilised even- two 
hours for two days and two nights, and then at intervals of three hours for the 
next twenty-four hours. The calomel is volatilised by means of a tin plate 
heated by a spirit lamp, and placed over a bowl of water so as to prevent fire 
in case of an upset. This treatment does not produce ptyalism; if carried 
on too long stomatitis, diarrhoea, and anaemia may supervene. The mouth 
should be kept swabbed out, and any secretion coughed up must at once 
be removed and disinfected. The medicinal treatment appropriate for 
diphtheria should be given (see infra). The only food should consist of fluids. 
Tracheotomy. — The operation of opening the trachea in cases of mem- 
branous laryngitis must be looked upon as a means of relieving the mecha- 
nical obstruction to respiration ; it can in no way influence the constitutional 
effects of the disease, though it may prevent the addition of gradual asphyxia 
to the other depressing influences of the poison. Further, we may, by the 
operation, prevent the spread of the membrane down the trachea, and thus, 
perhaps, lessen the risk of absorption of the virus as well as get rid of the 
obstruction. 1 What certainly may be looked for from the operation is that 

1 Vide R. W. Parker. 



Tracheotomy 1 97 

death from mechanical obstruction to the upper segment of the windpipe may 
be averted, and that the distress caused by dyspncea may to a great degree 
be relieved. It must not be forgotten that tracheotomy has its own dangers: 
first come the risks of the operation itself — haemorrhage, injury to important 
neighbouring structures, and entrance of blood into the trachea ; later, there 
are the dangers of septic absorption, the exposure of a raw surface to the 
diphtheritic poison, tracheitis, pneumonia, and so on, from exposure of the 
tracheal mucous membrane to cold ; that this is a real danger a paper of 
Dr. Wilks shows. 1 

While we have thus indicated the objections to and the limited uses of 
the operation, we would yet urge its performance in all cases where there is 
severe dyspncea ; we have no means of knowing that the child will die of 
asthenia, we do know that he will die of suffocation if unrelieved, and the 
other dangers mentioned are all usually avoidable by careful operating and 
after-management. 

Extreme prostration without distinct evidence of asphyxia, and the pre- 
sence of pneumonia or capillary bronchitis, may be looked upon as indica- 
tions that tracheotomy will be of no avail. If tracheotomy is otherwise in- 
dicated, the presence of bronchitis may not in all cases prevent the operation 
being successful. We have seen a case in which it succeeded perfectly under 
these circumstances as far as relieving the dyspncea went, though the child died, 
when apparently convalescent, from ulceration into the innominate artery. 

The younger the child the earlier should tracheotomy be done ; indeed, 
in children under three years once there is membrane in the larynx there 
is little hope but in tracheotomy ; but see p. 208. Inasmuch as the operation is 
nearly always one of urgency, we must be prepared to do it under unfavour- 
able circumstances as regards nursing, light, help, and appliances. It is, 
however, usually possible to improvise fairly serviceable arrangements for 
the operation itself. A dressing table or the top of a chest of drawers 
in private houses is the usual operating table. Candles give generally 
the best obtainable light when, as is so often the case, the operation has to 
be done at night, and care must be'taken that the lights are entrusted only 
to those members of the household who can be depended upon to bear seeing 
the operation. These makeshift arrangements, together with the small size 
and anatomical relations of the parts, the urgency of the case, and the 
movements of the trachea in difficult respiration, make this operation, 
though often lightly spoken of, one of the most anxious in surgery. 

If possible, at least one skilled assistant should be obtained besides the 
anaesthetist. As regards anaesthetics, it is in our opinion a question to be 
settled for each case ; if the child is so asphyxiated as to be unconscious of 
pain, and not likely to struggle, it is far better to do without an anaesthetic. 
We have seen chloroform prove fatal before the operation was begun ; on 
the other hand, if the case is operated upon earlier, and the child is conscious 
and restless, it is on all grounds better to give chloroform. 

The child then should be placed upon a table of convenient height, and 
the lights, if necessary, arranged carefully. Everything required in the 
operation should be Laid out upon a table or chair ready to hand before the 

1 Guy's Reports, ser. iii. vol. vi. 



■ I 



198 



Diseases of the Respiratory Apparatus 



child is taken out of bed, since at any moment the moving or the giving of 
the anaesthetic may increase asphyxia and demand instant action. 

As soon as the child is unconscious, and not before, since it increases the 
dyspnoea, one pillow should be taken from beneath the head and placed 
under the shoulders, so that the head falls back and fully exposes the front 
of the neck. Parker recommends a wine bottle wrapped in a towel as a 
neck support. The head must be held by an assistant exactly straight, so 
as to avoid any chance of the operator missing the mid line of the neck. 
The thyroid cartilage is then to be felt for, and an incision, one and a half 
to two inches in length, according to the size of the child, made in the middle 
line from the lower border of the thyroid cartilage downwards nearly to the 




(kiao-tiiyroid Membrtnie 
to Artery 
Cricoid CcLTtUagt 
Superior T-hyroid vt.cn. 



Fig. 24. — Anatomy of Child's Trachea. (From ' Gray's Anatomy.') 



top of the sternum. The first incision should be carried through the skin 
and subcutaneous fat ; the second assistant should then draw the edges of 
the wound apart with retractors, and the operator should by successive cuts 
divide the tissues until he reaches the intermuscular septum between the 
sterno-hyoids or lower down between the sterno-thyroids : on reaching this 
he should with a director tear through the line of junction, and the assistant 
should take them up with retractors. The tracheal fascia will now be ex- 
posed, and should be torn through in like manner, and the trachea bared. 
The tracheal hook is next fixed in the trachea, and drawn slightly forwards 
so as to steady the windpipe and make it prominent ; a short, somewhat 
round-shouldered knife — i.e. one rounded at the back and nearly straight in 
front — is then made to pierce the trachea, and as soon as it has entered 



Tracheotomy 1 99 

the handle is slightly depressed, and the windpipe is divided from below 
upwards for at least three-quarters of an inch. The knife is now laid 
aside, the dilator passed into the trachea and opened, and the hook re- 
moved ; a free blast of air and the driving out often of mucus or of mem- 
brane follows. If the trachea is free from membrane, the tracheotomy tube 
fitted with tapes is then passed in between or above the dilator blades, and 
the dilator is removed ; as soon as a blast of air through the tube shows that 
it is in place, the tapes should be tied round the neck, and the operation is 
over. The child should be kept upon the table well wrapped up, with a 
warm sponge over the tube, for a short time to recover itself, and that it may 
be seen that there is no bleeding or other complication ; after a quarter of 
an hour the inner tube may be put in after clearing away all coughed-up 
matter, and the child should be put into its cot and the steam kettle 
arranged. 

Such are the general outlines of the course of an operation in which there 
have been no complications and no hurry ; it is, however, seldom that such a 
favourable state of things occurs, and it will be convenient to consider more 
in detail the various difficulties that may arise. First, then, one or more large 
veins, inferior thyroid or branches of the anterior jugular, may be met with ; 
if there is no urgency these may be ligatured, either before or immediately 
after division, or forcipressure forceps applied. Should, by any rare chance, 
an artery of any size be wounded, it must of course be treated in the same 
way. In all cases the veins are necessarily intensely congested when dyspnoea 
is marked. In order to avoid danger of wounding veins, some surgeons lay 
aside the knife after the first incision and tear through the tissues down to 
the trachea with dissecting forceps or director. 

Next, the most rigid care must be taken to keep in the middle line ; in 
young fat children it is not difficult to miss the trachea, which in them is not 
only small, but so soft as to be readily compressed or pushed aside and so 
missed. Everyone has heard of, if not seen, cases in which the dissection 
has been carried to one side of the trachea, and thus the great vessels &c. 
endangered. In tracheotomy low down, the anterior jugular vein is the vessel 
most likely to be injured. This is, of course, of minor importance. 

The depth of the trachea must also be remembered, and the fact that it 
recedes from the surface towards the lower part of the neck. The deep in- 
cisions must not be carried too close to the sternum, or the innominate vessels 
will be endangered, nor must the trachea be opened so high up as to divide 
the thyroid cartilage and probably injure the vocal cords ; it is well, however, 
to get as low an opening as practicable, in order, if possible, to be clear of 
the obstruction. 

No regard need be paid to the thyroid gland, nor should any attempt be 
made in children to make a 'superior' or ' inferior' tracheotomy. In almost 
every case in which the operation has been done examination will show that 
two or three rings of the trachea and the cricoid cartilage, together with, oi 
course, the isthmus of the thyroid gland, have been divided that, intact. 
a laryngo-tracheotomy has been done, and this is as good as any other 
operation. 

It is not by any means necessarj to use a trachea] hook ; it" it is not em- 
ployed, the left forefinger should be used as a guide and the trachea steadied 



H9 



200 Diseases of the Respiratory Apparatus 

by it or between it and the left thumb while the knife is carried upwards by 
the side of the finger or between it and the thumb ; in many cases, however. 
the hook does undoubtedly simplify the operation. 

It is of great importance to have the skin wound very free, both to give 
room for the deeper steps of the operation and to prevent the possibility 
of discharge or air being pent up in the cellular tissue of the wound ; no 
stitches should ever be put in. The tracheal opening should be large, 
median, and vertical ; nothing is gained by a small opening, and much trouble 
may arise in inserting the tube. The knife should enter the trachea some- 
what sharply, but not with a stab or plunge which would endanger the 
posterior wall ; cases have been recorded where the knife failed to pierce 
the mucous membrane, and hence the tube was passed into the submucous 
tissue ; in other instances a tough diphtheritic membrane has been pushed 
before the knife and tube — under either condition, of course, no relief was 
obtained by the operation. 

If there is any large collection of membrane or of thick mucus in the 
trachea, the tube should not be inserted at once, but the edges of the tracheal 
wound should be held apart for the child to freely cough out the contents of 
the air passages, and for the surgeon to clear them away and examine the 
surface of the trachea so as to pick off any visible membrane above or below 
the opening. Parker advises the systematic use of the dilator and swabbing 
out the trachea and larynx with a feather dipped in solution of carbonate of 
soda before putting in the tube. 

The tracheal aperture may be held open either with the dilator or with 
artery forceps, or Golding-Bird's dilator may be worn for a time. 

In inserting the tube it is sometimes difficult to get it into the slitlike 
orifice in the trachea ; under these circumstances the dilator is useful, or if 
one is not at hand, one end of the opening may be depressed by the finger- 
so as to make the aperture gape. A bivalve tube is of course the easiest to 
insert for this reason, though it is not by any means the best variety. The 
surgeon should never be satisfied that the trachea is properly opened unless 
free blasts of air are driven out on coughing, nor that the tube is in the wind- 
pipe unless air and mucus are blown out through the tube freely. 

The instrument most commonly used to clear the trachea of membrane 
is a feather ; some of the shorter tail feathers of a pheasant Avill be found the 
best — if the longer ones are used, the end which is too flexible should be cut 
off. We have had some common brush pipe cleaners tipped with coralline 
for this purpose, and also a miniature bristle probang made to sweep out the 
trachea. Membrane can often be picked out with forceps. Aspirators of all 
kinds are of use chiefly if not solely for blood and the thinner form of mucus ; 
adherent membrane and thick mucus cannot be drawn out by them ; neither 
is sucking by the mouth any better, hence it is not worth the risk to the 
operator. Anyone who has tried it will know how impossible it is to suck 
out anything except the fluid material, and even for this suction is often un- 
successful. Parker, however, strongly advocates the use of aspirators after 
loosening and softening the membrane by installation of carbonate of soda. 1 
Where breathing has ceased or is becoming very feeble, artificial respiration 

1 Sodae carbonat. Jij, glycerine sij, water to oviij (Parker). 



Traclieotomy 20 r 

should be performed, and if necessary a catheter may be passed down the 
trachea and the lungs inflated. 1 

Such are the more important points about the operation itself in cases 
where everything can be done deliberately and Trousseau's classical advice, 
' Operez lentement, tres lentement,' followed. In many cases, however, if 
the operator is slow the child will be dead before the trachea is opened, and 
if not actually dead the almost complete asphyxia will seriously add to the 
dangers of the case. Under such circumstances it is necessary to cut the 
steps of the operation short ; a free incision through the skin, another down 
to the trachea, and the third upwards in the trachea itself. We have often 
had to operate in this way with three cuts, using no instrument except the 
knife and the tracheotomy tube ; after the first two incisions the left fore- 
finger is passed down to the trachea, which is steadied by it ; the opening 
is made and the finger kept as a guide for the tube, which is at once in- 
serted. The finger and thumb may be usefully employed to push back the 
tissues on each side and, as it were, press forward the trachea. In some 
cases there is free bleeding for a moment or two from the engorged veins ; 
this must be neglected, the tube put in at once, and the child instantly 
turned over on its face to prevent any blood from running into the trachea ; 
as soon as air enters the lungs freely the circulation is re-established and 
the venous bleeding ceases without any treatment. The objection to this 
mode of operating is that it is of course more difficult, and there is some 
risk of blood getting into the air passages ; it is, however, necessary in some 
cases. In very urgent suffocation the operation may even be done in one 
incision through skin and trachea upwards, but this can hardly ever be 
necessary, and has several objections, the chief being that in children the 
trachea can by no means always be felt through the skin, and there is 
great likelihood of emphysema from insufficiency of the superficial wound. 2 
Even if t the child is apparently] dead before the trachea is opened, the 
operation should be rapidly completed, a long feather passed down the trachea 
and withdrawn, and the artificial respiration performed. Recovery will often 
follow even if respiration has ceased for what appears a very long time. 

It is well to remember that venous bleeding in tracheotomy is always more 
formidable in appearance than in reality, and always ceases at once after the 
trachea is freely opened. 

Emphysema occurring at the time of the operation is due to too small a 
skin wound or to opening up the cellular tissue in attempts to pass the tube ; 
it may be very extensive and spread down into the thorax ; in such cases it is 
sometimes fatal from pressure upon the lungs. Champneys has shown ex- 
perimentally that there is serious danger of mediastinal emphysema and 
pneumo-thorax when artificial respiration or sudden violent inspiratory effort 
is made after division of the deep cervical fascia ; hence the tube or dilator 
should be put in quickly and the fascia disturbed as little as possible. 3 

A possible danger from entry of air into a wounded vein need only be 

1 Vide Jennings, Arch. Padiair. September 1884. 

8 St.-CScrmain operates by one incision downwards, beginning by perforating tin-, 
thyroid membrane. Neither this plan nor operation w ith the thermo-cautery has anything 
to recommend it. 

: ' Med. -Chi r. Trans. 1882. 



■ J 



.202 Diseases of the Respiratory Apparatus 

mentioned ; instant pressure on the vein and rapid opening of the trachea 
are the remedies. 

Opinions differ greatly as to the best form of tracheotomy tube for 
immediate use. The bivalve is the easiest to insert ; the lobster-tailed tube 
of Durham is open to the objection that it is very difficult to clean ; probably 
Parker's so-called angular tube is the best, and is certainly anatomically the 
most correct ; it has also the advantage of being polished inside. It is, 
however, a matter of little importance what shape of tube is put in for the 
first few hours, provided it is of sufficient size and has a movable shield to 
allow it to lie evenly. The largest size that the trachea will admit should 
always be used to give as much breathing space as possible and to prevent 
play of the tube in the trachea. Parker has shown that the diameter of the 
windpipe is exceedingly variable, and no rules for size in correspondence 
with age can be given. In any case it is advisable to change the tube after 
twenty-four or forty-eight hours, and this gives time for the substitution of a 
Parker's tube for any other that may have been used at the moment. After 
ninety-six hours the metal tube can often be replaced by a Morrant Bakers 
rubber one, or at least a metal tube of different length from that first em- 
ployed, or, better still, the tube may be in favourable cases left out altogether. 
As soon as the trachea has been cleaned and the child has become quiet 
after the operation, i.e. usually in about half an hour or less, the child 

should be removed to the tent, the arrange- 
ment of which has been already described. 

The lower part of the wound should be 
dusted over with iodoform, and a piece of 
gauze slipped beneath the shield of the tube 
to protect the skin and wound from it. If the 
edge of the shield cuts into the wound, the 
tube does not fit well and probably the inner 
end is pressing upon the tracheal wall ; it 
is either too long in the straight part or the 

Fig.' 25.— Parker s Tube. . *•«**■ 

curve is wrong. A single layer of gauze wet 
with 1-40 carbolic or some other antiseptic solution should be laid over 
the mouth of the tube and removed when there is any coughing. 

The child must be constantly watched, and at the least sign of dyspnoea 
or any cough the tube should be cleaned with a feather, and coughing 
excited, watching for the moment when mucus appears at the mouth of the 
tube to wipe it away before it is drawn in again. The inner tube should be 
put in as soon as the child has settled down, and taken out ever}'- half-hour 
or oftener at first to be cleaned. Special watch must be kept for any sudden 
plugging of the tube by pieces of detached membrane or thick mucus — a 
frequent cause of sudden death after tracheotomy — immediate removal of the 
tube and membrane is required in such circumstances. Abundant discharge 
of thin mucus is a good sign, in so far as there is less likelihood of there 
being any membrane in the trachea if free secretion occurs. 

After-management. — Success in the results of tracheotomy cases depends 
more upon after-management than upon anything else, and if surgeons could 
nurse their own cases the mortality after the operation would be much less. 
Constant watchfulness, readiness to remove the tube at together and -clean out 




Tracheotomy 203 

the trachea — if membrane continues to form, this should be done at least 
once daily ; the timely administration of stimulants, regulation of temperature 
and moisture are essentials, and can only be satisfactorily seen to by the 
surgeon himself. Cocks ] well insists upon this, and points out that sudden 
obstruction is most often due to inspissated mucus, not to membrane ; this 
thick mucus is secreted generally about twenty-four hours after the operation, 
and at the end of three or four days the discharge becomes thinner and 
more puriform (Jennings). 

It is well to feed the child by nutrient enemata for the first few hours, but 
if he is thirsty a few teaspoonfuls of iced milk may be given. During the 
first few days the milk not infrequently comes out in part through the 
tracheotomy tube from imperfect closure of the glottis during deglutition, and 
not, as might be supposed, from any accident to the oesophagus ; on account 
of this occurrence it has been advised to give more solid food by the mouth. 
A certain amount of risk is incurred from this imperfect power of swallowing, 
in that food may pass into the lungs and set up the so-called 'deglutition 
pneumonia ; ' any such danger may be avoided, as pointed out by Dr. 
Habershon, jun., by feeding the child through a soft catheter ; from 2 to 6 oz. 
of milk may be given in this way every four hours,'- but the plan is rarely 
required. 

If possible the tracheotomy tube should be removed altogether on the 
fourth or fifth day, but this must depend upon how far the disease has sub- 
sided ; if membrane is still coming away, the tube must remain, and it may 
be the eighth or tenth day before it is got rid of. If, as not infrequently 
happens, the dyspnoea returns on closure of the orifice of the tube with the 
finger (always supposing that the tube has a perforation at the bend) or on 
its removal, the difficulty is due to the presence either of membrane or of 
granulation tissue, which may form a polypoid mass springing from the site 
of some patch of membrane, from the edge of the wound, or from an ulcer 
due to the pressure of the tube. Granulation masses, according to Parker, 
are most common about the fourth to the eighth day, and may be expected 
if there are exuberant masses on the margin of the tracheal wound. Morell 
Mackenzie says they occur from the fifteenth to the thirtieth day, never after 
two months. Parker treats them by the application of nitrate of silver. 
Black patches seen on the outer tube when it is removed are said to indicate 
ulceration at the corresponding spot of the trachea, and should be looked 
upon as an indication for change of the tube to one of different length 
(Parker). Or the dyspnoea may be due to adhesions in the larynx or 
possibly paralysis of the laryngeal muscles, inflammatory softening of the 
trachea, or swelling of the mucous membrane. 

Where, then, the tube cannot be removed entirely after the fifth day, the 
metal one should be replaced by a rubber one, or frequent changes made in 
the length of the tube, and daily attempts made to dispense with the tube 
altogether. Should the obstruction continue, search must be made for iis 
cause ; the most common is the granulation mass which may sometimes 
be sccmi on using the dilator and be removed, its base being touched with 
nitrate of silver. Failing this, it is well to wait a week or so and allow the 
child to regain strength ; it should then be examined under an anaesth< 
1 A rchives of Pediatrics, January 1884. '-' St, /•'. [885, 



■ i 



204 Diseases of the Respiratory Apparatus 

and, failing the finding of granulations or other obvious cause, a flexible 
probe should be passed up through the glottis from below and a piece of 
silk carrying a small sponge be attached to it ; the probe should then be 
drawn out through the mouth, and the sponge carried through the larynx 
sweeps it out, breaks down any adhesions, and clears away mucus or any 
granulations there may be. We have by this means succeeded in restoring 
the breathing powers after many attempts at doing without the tube for a 
long time. 

The dangers, then, of the too prolonged retention of the tube are the 
possible development of granulation masses and ulceration of the trachea, 
which may either lead to haemorrhage from perforating the innominate artery 
or vein, or to subsequent tracheal stenosis from cicatricial stricture. Roger,, 
in 1859, and Heilly [Le Progres Medical, November 29, 1884), estimated that 
in about one in five of the cases of tracheotomy there is ulceration of the 
trachea, but these results are from post-mortem observations. The ulceration 
may be either on the anterior or posterior wall of the trachea and gives rise 
to no special symptoms at the time, unless some important vessel is opened. 

Sometimes mere nervousness and fear of suffocation prevent the removal 
of the tube ; in such cases attempts must be gradually made by the use of a 
tube with a large fenestra to allow the passage of air through the larynx, while 
the external orifice of the tube is closed with the finger or a cork for gradu- 
ally increased periods of time. Careful watch must always be kept upon 
these cases for fear of sudden asphyxia, which may come on after removal 
of the tube, as soon as the tracheal orifice becomes small, or even later than 
this from growth of granulations from the inner surface of the wound. In 
such cases the wound may require to be reopened and the tube to be inserted 
afresh. In some few cases the tube can never be dispensed with, and has to 
be worn permanently ; but usually some cause of obstruction can be found. 
Sometimes a tough dense cicatricial membrane forms about the lower aper- 
ture of the larynx or upper part of the trachea, and requires removal by 
enlargement of the tracheotomy opening or by thyrotomy. Intubation with 
or without removal of cicatricial tissue is effectual in some cases. 1 In any 
case where the tube has to be long retained, great care must be taken to 
avoid ulceration and to see that the tube is not corroded ; it has several 
times happened that the tube has dropped off the shield and fallen into the 
trachea after long wear. 

As to the application of lotions &c. to the interior of the trachea after- 
operation, the number of specifics is as great as that for the throat ; the soda 
lotion and lime water 2 do, no doubt, soften the membrane and mucus, and 
allow it to be more easily detached ; of the other remedies probably the best 
is the instillation of 2 or 3 drops of 1-2000 mercurial solution. The applica- 
tions may be made with a brush or spray producer, or a drop or two may be 
instilled through the tube from time to time. Smearing the tube each time 
it is replaced with iodoform ointment is a good plan. The wound should be 
swabbed over daily with a solution of perchloride of mercury (1-2000), and 
then powdered with equal parts of iodoform and boric acid. 

After the operation the child is greatly relieved, usually falls asleep, and all 

1 Vide Pitts and Brook, Lancet, January 10, 1891. 

2 Lime water is soon rendered inefficient by the C0. 2 of the expired air. 



Tracheotomy 205 

goes on well for twenty-four or forty-eight hours, and then in fatal cases death 
occurs, often suddenly. This sudden death may be due to various causes ; 
blocking of the tube with detached membrane or mucus, extension downwards 
of the disease, possibly irritation of the vagus (Parker), simple asthenia or 
poisoning by the disease, pneumonia, or cardiac failure. 

There is no doubt that the majority of cases of tracheotomy for diphtheria 
die ; the mortality varies with the epidemic and with the operator, for neces- 
sarily the surgeon who will only operate in the most favourable cases will 
have a lower mortality than he who gives a chance of relief to less hopeful cases 
as well. Hence statistics are of no value. It is, however, roughly true that 
a large proportion of the cases described as croup recover after tracheotomy, 
while those classed as diphtheria mostly die. 

Age has a very important bearing on the success of the operation. 
•Children under 2 years comparatively seldom recover ; x the feebleness of 
the child, the increased difficulty of the operation and of the subsequent 
management, all make the prospect at this age worse. R. W. Parker has 
htad 50 per cent, of successes in his own practice, but this must be considered 
far better than the average result. 2 

Archambault, in the Paris Children's Hospital, gives the following table 
of tracheotomy cases : 



I 


-3 


vears 


3- 


-4 


55 


4- 


-5 


•>•) 


5- 


6 


•>•> 


above 6 





Cases 


Recoveries 


976 


I04 


820 


175 


736 


174 


497 


I48 


547 


I98 



For the general management and feeding of diphtheria cases, as well as 
for the treatment of the fauces and mouth, see DIPHTHERIA. 

Apart from diphtheria or croup, tracheotomy may have to be considered 
in cases of scalds of the glottis, usually the result of an attempt to drink from 
the spout of a tea kettle. In such cases, as Dr. Wilks has shown, a false 
membrane may be produced exactly like that of diphtheria.' 1 The sym- 
ptoms usually come on immediately, and in slight cases soon subside if the 
child is kept in bed in a warm moist atmosphere. Sudden spasm, bronchitis, 
and pneumonia, and the formation of false membrane are the chief dangers. 
The treatment of such cases consists in keeping the child in a tracheotomy 
tent and giving antimony or an emetic. If the child is steadily getting 
worse, tracheotomy should be performed. The tube may be removed 
usually on the third to eighth day. Scarification is often recommended, but 
is more easy to write about than to perform. 

Foreign bodies often find their way into the air passages of children. 
A bead, or grain of maize, or a plum stone, or other foreign body is held 

1 But Lindner, Jahrbuchf. Kinderheilk. B. xx. 11. 2, records 38 per cent of successes 
for ' croup and diphtheria,' and most o\ the successes were in the second year of life ; and 
Chaym, Archiv f. Kinderheilk. B. iv. 11. m, u, has collected aao successful cases under 
8 years; the youngest cases are 6 weeks and g weeks respectively ; the latter, however, 
was for post-pharyngeal abscess. — Berliner klin, Woch. 1880. 

2 Edin. Med. Jour. November 1888. 

" Guy's Reports, c85o, and Bryant in the same number. 



206 Diseases of the Respiratory Apparatus 

in the child's mouth, and a sudden inspiration may cause it to pass into the 
larynx. The body may lodge in the upper opening- of the larynx or in the 
rima, or may pass into the trachea or either bronchus, usually the right. 

Parker records a case in which a caseous lymphatic gland ulcerated its 
way into and blocked the trachea. 1 

If the body is in the larynx there will be dyspnoea and more or less loss of 
voice, with hoarse or ringing cough, and if in the trachea possibly a loose 
rattling sound may be heard on listening over the front of the neck, indicating 
the movement of the body in the trachea. If the substance is lodged in the 
bronchus there will be impaired breath sounds, and possibly collapse of the 
lung on the same side. 

If the history is clear, tracheotomy should at once be performed, as sudden 
asphyxia often comes on quite unexpectedly ; hence, urgent symptoms should 
not be waited for. The opening in the trachea should be free, and the edges 
should be held apart to allow of the ready expulsion of the body, which is 
often blown out at once. If this does not occur, the larynx should be searched, 
a probe being passed in from below and the finger made to explore the 
throat from the mouth. If the body is lodged below the opening, the child 
should be inverted and shaken, and if this is unsuccessful an attempt should 
be made to extract the substance with forceps or a brush passed down the 
trachea. Bronchitis and pneumonia usually speedily result if the foreign 
body is not removed. 

Should the attempt at removal fail, if the body is in the larynx and cannot 
be pushed up into the mouth or removed from below, it is probably better 
to follow Holmes's advice and divide partially or wholly the thyroid cartilage 
so as to expose and remove the impacted mass ; the operation is likely to do 
less harm than the retention of the foreign material. If the substance is 
lodged in the lungs, it may possibly be removed at a second attempt or 
may become loosened and coughed up ; occasionally such bodies ulcerate 
their way out and may even reach the surface of the chest. In other cases 
death results from pneumonia or pulmonary abscess. 

Certain other conditions may demand tracheotomy in children — congenital 
syphilitic laryngitis, chronic simple laryngitis, papilloma, or, as already men- 
tioned, pressure of pharyngeal abscesses. 

Intubation of the larynx has been of late years practised by O'Dwyer, 
Waxham, and others, chiefly in America, as a substitute for tracheotomy. It 
has been urged in its favour that it is a less severe measure than that opera- 
tion, and is likely to be permitted by friends when a cutting operation is re- 
fused ; that it does not prevent opening the trachea later, should that become 
necessary, and that it is efficient, while it does not expose a raw surface to 
the diphtheritic poison nor allow unwarmed air to reach the lungs. A special 
set of instruments is required for this plan. From 20 to 30 per cent. 2 of 
successful results have been obtained, but several drawbacks to its use are 
admitted, such as the difficulty of the manipulation, the liability to displace- 
ment of the tube, and its obstruction by membrane. Our experience of the 
operation has shown that a little practice is required to learn readily to intro- 
duce the tube : it is much more difficult to remove the tube from the larynx. 

1 Brit. Med. Jour. October i, 1890. 

2 Vide Waxham, Brit. Med, Jour. September 29, 1888. 



Intubation 



207 



Several improvements have been made in the apparatus, and the method has 
no doubt a considerable though limited field of usefulness. Intubation, 
as suggested by Symonds, is certainly useful in some cases where after 
tracheotomy there is a difficulty in getting rid of the tube. 1 

In one instance in which we performed intubation upon a living child the 
result was disastrous ; a portion of the membrane was pushed down before 
the tube, and the child instantly choked : it was only by immediate tracheo- 
tomy and the use of artificial respiration that breathing was restored 




Fig. 26. — O'Dwyer's Intubation Apparatus. The figure shows the 'introducer' with a tube 
fitted on. A separate tube is also shown. 

Others have had similar experience. We have had some experience of the 
method in various forms of laryngeal obstruction, and have not been led to 
take a very favourable view of its suitability for cases of diphtheria where 
false membrane in any quantity is present. Of eleven cases of intubation 
under our care, in three success followed, in three tracheotomy was 
subsequently successfully performed, and in four instances the children died 
in spite of tracheotomy. The operation appears best adapted for cases 




Fig. 27.— O'Dwyer's Extractor. The jointed beak fits into the tube and hold; 
the lever is depressed by the thumb of the operator. 



it firmly when 



where there is little or no false membrane — i.e. certain types oi acute 
laryngitis, the less severe forms of diphtheria, where tracheotomy is for any 
reason undesirable, and for use in cases where mechanical obstruction 
remains after tracheotomy, or results from cicatricial contraction in the 

1 For further details we must refer to the Medical Chronicle for 1887, where abstracts 
of numerous papers on the subject will be found ; also to the . irckives of P [887, 

and Waxham's paper already referred to, and to the Appendix of the present « 
also to Hall's Hook on Intubation, and Northnip, Brit. Med. four. December -\\ l8< 



2o8 Diseases of the Respiratory Apparatus 

larynx. It is certainly unsuitable for bronchitic and pneumonic patients. 
Recently a special pattern of short wide tubes has been used for cases where 
there is much loose membrane or discharge. 1 

Lovett, 2 from a study of 858 cases operated upon at the Boston City 
Hospital either by tracheotomy or intubation, concludes : ' In general 
I would be glad to advocate the performance of tracheotomy instead of 
intubation in most cases of severe laryngeal diphtheria, except in the cases 
of children under two years, when intubation is to be performed.' 

The apparatus used for intubation, and figured above, consists of a 
special tube with an ' introducer ' and ' extractor.' The child should be 
swathed in a blanket and held upright in the nurse's arms. The mouth is 
held open by a gag, a tube of proper size selected, threaded, and its pilot 
screwed on to the introducer ; the left forefinger passed to the back of the 
throat pulls forward the epiglottis and serves as guide to the tube. Any 
•difficulty in introducing the tube may, we have found, be got over by waiting 
for an inspiratory effort on the part of the patient and then slipping in the 
tube : this is a little practical point of much value. As soon as the tube is 
in the larynx the introducer is withdrawn with the pilot, and if the tube is in 
position the thread may be also withdrawn. We are of opinion that it is, 
however, much better to leave the thread in the tube to facilitate extraction ; 
usually it sets up little or no irritation. The tube is then left in position for 
a time varying from a few hours to two or three days, according to the 
-circumstances of the case. If left too long it may cause ulceration of the 
larynx or trachea. 3 To remove it an anaesthetic may or may not be given, 
the extractor is introduced into the opening of the tube, which is then with- 
drawn. If too small a tube is used, it may slip into the trachea. Without 
practice the tube is apt to be passed into the oesophagus. 

After the introduction of the tube, relief, though not necessarily imme- 
diate, is usually speedy. There is sometimes difficulty in feeding, from a 
tendency for fluids to pass into the trachea. If this difficulty occurs it can 
be met by feeding the child with its head hanging far back or by giving 
semi-solid food. 

Chronic laryngitis — Both infants and older children suffer from chronic 
hoarseness, with occasionally acute or subacute exacerbations, with croupy 
symptoms. Such cases may take their origin in a past attack or attacks of 
subacute laryngitis, a certain amount of thickening being left behind. Other 
cases are apparently syphilitic, especially in infants. Tubercular laryngitis 
may also occur, but it is certainly uncommon. The larynx is also sometimes 
affected in cases of chronic pharyngitis where the tonsils are enlarged and 
perhaps post-nasal growths also exist. If the symptoms do not yield to 
astringent applications or the use of caustics such as nitrate of silver, there 
may be so much progressive thickening and dyspnoea that tracheotomy 
may be required ; this is, however, very rarely the case. 

Papilloma of the larynx is a rare affection, consisting in one or more 
warty outgrowths from the neighbourhood of the true vocal cords. The 
symptoms are aphonia and usually intermittent but increasing dyspnoea, 

1 Northrup, Brit. Med. Jour. December 29, 1894. 

2 The Medical News, August 27, 1892. 

3 Carr, Lancet, March 28, 1891. 



Papilloma of the Larynx 209 

coming on without obvious cause. Where laryngoscopy is practicable, inspec- 
tion shows the warty mass or masses usually about the anterior part of the 
•glottis. Sudden obstruction of the aperture may result from spasm set up 
"by impaction of a pendulous growth between the cords, or gradual asphyxia 
may come on. Three modes of treatment are possible — removal of the 
•growths by endolaryngeal operation, a method applicable only to late child- 
hood and adults ; the second is tracheotomy, with or without an attempt to 
remove the growths from the tracheotomy wound ; and the third is thyrotomy, 
with excision of the warts when fully exposed. The last plan, which is the 
•simplest, is open to the objection that injury is likely to be done to the vocal 
•cords and permanent aphonia may result. Several successful cases by 
Parker, Davies-Colley, and others, have, however, been recorded. On the 
whole, in this disease, it is probably best to perform thyrotomy. 

In two cases lately under treatment at the Children's Hospital by our 
•colleagues Dr. Hutton and Mr. Collier, and by ourselves, repeated operations 
were required both in the shape of thyrotomy and of scraping out the 
growths through the laryngeal aperture. The tendency to recurrence was very 
marked indeed, and more than once the windpipe had to be reopened to 
prevent suffocation after the children had appeared to be convalescent. In 
both cases it was found impossible to dispense with a tube. The growths 
sprang from all parts of the interior of the larynx and upper portion of the 
trachea. Hutton l points out that cases of spontaneous disappearance of 
these growths have been recorded after portions had been coughed up, also 
after tracheotomy without further operation, and after an attack of one of the 
exanthemata. 

1 Hutton, Med. Chron. vol. i. N.s. 1894. 



2io Diseases of the Respiratory Apparatus 



CHAPTER XII 

DISEASES OF THE RESPIRATORY APPARATUS— Continued 

Bronchitis and Catarrh 

Catarrh of the bronchial tubes is a common affection at all periods of life 
and in every social grade, but it is in early childhood that it is perhaps the 
most common, and it is at this'period that it assumes the greatest importance 
from the diseases which are liable to follow in its train. In old age, when 
the lungs are damaged by emphysema, and the chest walls have lost their 
elasticity, bronchitis is apt to be a serious and often fatal disease ; but not 
less so is it in the very young, in whom the chest walls are alike wanting in 
elasticity and rigidity, the bronchial tubes easily collapse, and the lungs 
very readily join in the inflammation. The greatest liability appears to occur 
during the first two years of life ; certainly at this age it is most fatal. Ex- 
posure to cold is in a large number of cases the exciting cause ; climatic 
influences are seen, especially in late autumn or early winter, in the large 
number of cases of chest affections which occur at this period. That the 
larger number of cases should occur among the lower and worst-housed 
class is only what is to be expected, inasmuch as the lives of the infants and 
children are spent either in the foul and stuffy atmosphere of an overcrowded 
and ill-ventilated house, or they are exposed, imperfectly clad, to all sorts of 
weather in the streets. 

The predisposing causes are many ; some children seem to inherit a 
tendency to bronchial catarrh, and, in spite of the greatest care and the 
most constant ' coddling,' suffer every few months, perhaps for the whole of 
the winter, from bronchial catarrh or severe colds, which pass into bronchitis 
with the greatest readiness ; dentition, rickets, measles, whooping cough, 
intestinal catarrh frequently play an important part in the production of a 
bronchitis. During the time that a tooth is being cut children seem very 
apt to suffer from catarrh, which in the winter affects the bronchial tubes 
and in summer the intestines. Pressure of the tooth on the gums seems to 
act reflexly in producing a catarrh, sometimes with more or less spasm, as 
the child becomes wheezy at night, sibilus being heard all over the chest, 
while in the morning it will be perfectly well. This may happen several 
nights in succession. Rickety children are specially prone to suffer from 
bronchial affections, and in them it is especially serious on account of the 
softness of the ribs, and the weakness of the muscles of respiration, resulting 
in deformed chests and collapsed lung. 

Symptoms a?id Course. — The attack is often preceded by a cold in the- 



Bronchitis 2 1 I 

head, the infant sneezes, its nose runs, and it begins to cough. If the 
bronchial catarrh which follows is mild, and the catarrh does not extend 
beyond the trachea and large bronchi, the general symptoms are slight : 
there is no distress, no dyspnoea, only a troublesome cough, perhaps some 
wheezing during respiration and a slightly elevated temperature at night. 
In the more severe attacks, in which the smaller bronchial tubes are involved, 
their mucous membrane being swollen and the secretion thick and viscid,, 
dyspnoea from obstruction to the air entering the lungs will be present. 
The pulse is hard and accelerated, the number of respirations increased 
according to the amount of obstruction, the alae nasi working, the skin 
hot, and the infant restless and thirsty. On placing the ear to the chest, dry 
hissing or snoring sounds will be heard during inspiration, as the air rushes 
through the pulmonary divisions of the bronchi, in the severer cases entirely 
obscuring the respiratory murmur. In the milder attacks rhonchi will only 
be heard with some respiratory movements, being more especially heard at 
the roots of the lungs. 

In infants and young children, especially if their ribs are softened in 
consequence of rickets, there is recession of the chest walls, chiefly at the 
epigastrium and lower lateral region of the chest, due to the imperfect filling 
of the lungs, the chest wall falling in in place of the lungs expanding. In a 
later stage the sibilant or rhonchial sounds become mixed with moist rales : 
these are not distinctly and sharply crepitant, as of bubbles passing through 
thin fluid, but indistinct bubbling sounds as of air forced through thick 
tenacious mucus. The moist sounds succeeding the dry point to a freer 
secretion of mucus from the hitherto swollen and congested mucous mem- 
brane. In some cases in infants mucous bubbling rales are heard from the 
first. If convalescence is quickly established, the abnormal sounds are 
gradually replaced by the normal respiratory murmur, though rhonchi or 
rales may be heard for some days or weeks. Percussion of the chest walls 
during an attack of uncomplicated bronchitis shows the resonance normal, 
although perhaps there may be some hyper-resonance at the sub-clavicular 
regions from the presence of more or less emphysema. 

In most attacks of bronchitis there is usually more or less disturbance of 
the digestive organs. The bowels may be confined and distended with 
flatulence, the tongue is coated, and there is often more or less vomiting. 

The fever in uncomplicated cases is never high ; there may be an even- 
ing rise of a degree or two, while the morning temperature may be normal 
or subnormal, especially in weakly children. The cough, which in the early 
stages is hard, in the later stages becomes looser, mucus is coughed up into 
the pharynx and then quickly swallowed, unless extracted by means of 
the nurse's finger. Children under five years rarely expectorate — mucus is 
coughed up, but they have not the sense to spit it out. 

An attack of bronchitis usually lasts a week or ten days and ends in 
recovery, leaving the child subject to a second attack. 

Complications. — Bronchitis in infants and young children is frequently 
accompanied by one or more complications, the commonest being collapse 
of the lung, catarrhal pneumonia, bronchiectasis, and emphysema. In a 
fatal case it is almost certain that om\ or more often all four, of these com- 
plications will be found. 

p j 



2 r 2 Diseases of the Respiratory Apparatus 

Collapse of Iiung-. — During an attack of bronchitis or bronchial catarrh 
it is not uncommon to note that the respiratory murmur is weak or absent 
over a portion of lung — as, for instance, one or other base ; then perhaps after 
a vigorous cough a plug of mucus is dislodged from a large bronchus and 
the breath sounds, with perhaps some loose rales, are heard over the same 
area. At other times the breath sounds are absent, and by the next day the 
ordinary respiratory murmur will again be heard. In this case a plug of 
thick mucus lodged in one of the larger divisions of the pulmonary bronchi 
prevents the ingress and egress of the air from the lung, but is expelled 
and coughed up by an extra effort. 

If, however, thick mucus is drawn into the smaller bronchi, perhaps 
filling up a series of small branches, the most powerful expiratory effort the 
child can make fails to clear the occluded bronchi, especially when the re- 
spiratory muscles are weak and the ribs are soft and easily bend. Two 
things are now certain to happen — the lung supplied by the occluded bronchi 
collapses and more or less dilatation of the bronchial tubes and emphysema 
of the neighbouring lung occurs, unless the chest walls fall in to take the 
room of the collapsed lung. The lung collapses in consequence of the 
absorption of the imprisoned air, the air entering the blood-vessels, as 
shown by the experiments of Lichtheim. It is clear that this collapse of 
lung and vicarious emphysema at least temporarily damages the lung, and if 
this should occur to any great extent in acute bronchitis, it adds considerably 
to the danger of death by asphyxia. 

The symptoms to which collapse gives rise are not always very definite, 
and unless tolerably extensive there may be no sign of its presence. In 
some cases it may supervene suddenly, possibly by the sucking in of mucus 
which has accumulated in the trachea during sleep into the bronchial tubes, 
the dyspnoea becoming urgent, the child's lips blue ; it rolls about in its 
cot struggling for breath, and convulsions come on which perhaps prove 
fatal. In other cases, while the symptoms may be alarming for the time, 
they quickly pass away, a result due to the mucus being expelled. If the 
collapse is scattered in patches throughout the lung, especially if accom- 
panied by emphysema, it will be impossible to detect it by any physical signs ; 
there may be hyper-resonance due to the emphysema, weak breath sounds, 
and perhaps some moist rales. If any extent of lung is involved, as part 
of an apex or base, there will be some loss of resonance, but this is rarely 
well marked unless some broncho-pneumonia be associated with it, a pneu- 
monic patch and a collapsed patch lying side by side. The respiratory 
murmur over the collapsed patch is weak, and rhonchus or moist sounds may 
be heard. In some cases there appears to be a mixed condition of collapse 
with much congestion of the vessels and oedema, or possibly, as some authors 
believe, the collapsed lung becomes the seat of a low form of pneumonia, 
leucocytes and epithelioid cells being present in the air sacs. 

Bronchiectasis and Emphysema. — Dilatation of the bronchi frequently 
takes place during acute bronchitis, the walls of the medium-sized and small 
bronchi being thin and their calibre increased, a result no doubt due to in- 
flammatory softening of their walls. Emphysema is also constantly present 
in association with dilated bronchial tubes. The chest walls during an acute 
attack assume the position of inspiration, and, particularly the infraclavicular 



Chronic Bronchitis 



213 



regions, become hyper- resonant, while the expiratory murmur is prolonged. As 
already remarked, compensatory emphysema is constantly present in asso- 
ciation with broncho-pneumonia and collapse. Bronchiectasis takes place in 
association with chronic pleurisy and fibroid conditions of lung. 

Chronic Bronchitis and Bronchiectasis 

Children and infants, like adults, suffer from chronic bronchial catarrh ; 
they recover slowly, and then perhaps within a few weeks another attack 
supervenes. Some children show such a tendency to these attacks that they 
have to be kept prisoners almost all the winter, as exposure to even slight 
cold is sufficient to lay them by for weeks. Frequent and long-continued 



HMRHH 
MUHHilir 





Fig. 28. — Temperature Chart of a case of Bronchitis with disseminated patches of Pneumonia. 
Boy of 5 years. Recovery. 

attacks of bronchitis are certain sooner or later to produce emphysema, 
dilated bronchial tubes, and dilatation of the right side of the heart and the 
veins which empty into it. Such children present a typical picture ; they 
are mostly thin, with rounded drooping shoulders, barrel-shaped chests, 
enlarged superficial jugular veins and often injected capillaries on the cheeks. 
In some of these more or less dullness may be detected at one base or another, 
and they constantly cough up large quantities of very foul mucus. Such cases 
are anything but welcome inmates in a ward on account of their extremely 
foetid expectoration. They are very chronic and not much amenable to 
treatment. We have attempted external drainage o\ the dilated bronchial 
tube, but have not met with much success, as the patient has gradually 
sunk. In the milder cases such children with care improve greatly, and 



214 Diseases of the Respiratory Apparatus 

frequently by puberty lose their tendency to bronchial troubles, and grow up, 
if not strong, at least not with impaired health. On the other hand, there is 
always the risk of an intercurrent and perhaps fatal pneumonia ; we have 
seen children of this class with marked emphysema come regularly into 
hospital perhaps twice in a winter with attacks of croupous pneumonia. 
There is a risk of chronic bronchitis passing into a chronic broncho- 
pneumonia, the lung tissue around the dilated bronchi becoming caseous 
and indurated. There is also the risk of tuberculosis, but we have not often 
been able to trace a connection between chronic bronchitis and tubercle, 
though those suffering from chronic bronchitis are often mistaken for 
phthisical subjects. 

Broncho -pneumonia 

In many cases the attack begins with a bronchial catarrh and quickly 
passes on into a broncho-pneumonia, the inflammation extending from the 




Fig. 29. — Temperature Chart of a case of acute Broncho-pneumonia in a boy of 2I years ; death 
fifteenth day. At Khz. post-mortem both bases of lungs showed generalised broncho-pneumonia 
with ' graines jaunes. ' 

bronchi into the air-cells. In other cases the bronchial symptoms may be 
slight or absent, and the attack may closely resemble a croupous pneumonia. 
Between these two types all gradations may be met with. When the pneu- 
monia supervenes on bronchitis, all the symptoms become exaggerated, the 
child is restless, the cough shorter and more hacking, the skin hot and dry, 
the evening temperature usually reaching 103 or 104 with morning remis- 



Broncho-pneumonia 2 \ 5 

sions of several degrees, so that the fever assumes a remittent type ; sometimes 
there are evening instead of morning remissions, the temperature being at 
its lowest in the evening ; the dyspncea is usually great, the respirations 
numbering forty or fifty, but varying with the amount of fever and extent of 
lung involved. If the pneumonia is extensive, the face wears a distressed 
expression, the alas nasi work vigorously, the child lies weak and helpless in 
its mother's arms, too feeble to cry, or if it resists examination for a while it 
is soon exhausted and passively submits. 

An examination of the chest, if made when the attack is fully developed 
and severe, shows that the accessory muscles of respiration are brought into 
play, the respirations are rapid and shallow, with recession of the epigastrium 
and intercostal spaces. The percussion note varies according to the position 
-of the consolidated lung ; this may involve an extended portion at one or 
both bases, at an apex, or be scattered in patches over the lungs. To detect 
the pneumonic portions both light and strong percussion should be practised, 
carefully comparing any spot where the resonance appears impaired with 
the opposite side. There may be hyper-resonance, especially anteriorly, 
from the presence of emphysema. A considerable amount of pneumonia 
may exist if diffuse or patchy without any definitely impaired resonance. 
There is never complete dullness in pneumonic consolidation unless much 
lymph or some fluid be present. On auscultation rhonchi are usually heard 
over the chest, while over the pneumonic portions rales of a consonant or 
ringing character are heard, which contrast with the subcrepitant rales of 
a simple bronchitis, inasmuch as they are more intense, from the fact of 
their travelling to the ear through consolidated lung. Even though no 
consolidated lung can be detected by percussion, the presence of consonant 
intensely ringing rales with a temperature of 103 or 104 points almost cer- 
tainly to pneumonia. 

In the early stages the respiratory murmur is weak, later there is mostly 
well-marked bronchial breathing over the dull area. If a fatal result is 
about to occur, the respirations become more hurried, the distress greater, 
and the pulse weaker and weaker ; rales and rhonchus are heard over the 
whole chest, the heart flags, and the child becomes pallid and comatose, 
death taking place with symptoms of toxaemia on account of the bronchi 
becoming choked and the lungs consolidated. The temperature usually 
falls towards the close; the child is frequently convulsed. If, however, the 
attack takes a favourable turn, towards the end of the first week or earlier 
the temperature approaches normal, the breathing is easier, and the child, 
instead of concentrating his whole attention on himself, begins to notice 
those about and to play with his toys. The physical signs change but 
slowly, the bronchial breathing and rales being heard perhaps during the 
second or even the third week.. 

While the above is the description of a typical attack, the pneumonia 
may be of much less well-marked character. The child may seem ill with 
little or no cough, while there is loss of appetite, coated tongue, and feverish- 
ness, especially well marked during the afternoon or evening, An examina- 
tion of the chest may at first yield no positive result, yet in a day it will be 
noted that there is a patch of lung at the extreme base, axilla, or near the 
root where the air does not enter well, and the respiratory murmur is replaced 



2l6 



Diseases of the Respiratory Apparatus 

In a few days or a week 



by breathing of a distinctly bronchial character, 
the temperature may again become normal. 

Sometimes an attack of broncho-pneumonia closely simulates the croupous 
variety, and there may be a doubt as to which category to refer it. The 
onset may be sudden, accompanied by a convulsion or series of convulsions, 
the temperature may rise to 104 or 105 (see fig. 30), the physical signs may 
point to an extended portion of lung being involved, and only the course of 

the attack, the temperature becoming" 
intermittent, and reaching normal gra- 
dually by lysis, would seem to indi- 
cate that the attack is rather of the 
catarrhal than the croupous variety. 
Some cases may from first to last be 
open to doubt. 

Course. — While broncho-pneumonia 
is frequently an acute disease, proving" 
fatal in a few days or a week, its course 
in many cases is subacute or chronic,, 
lasting for several weeks or even more 
and yet ending in apparently complete 
recovery. In some instances recovery 
takes place, to be followed by a re- 
lapse, the temperature again becoming: 
remittent for a few days or a week. 
The termination of the fever is nearly 
always by lysis. In these protracted 
cases the possibility of tuberculosis or 
a local empyema must always be borne 
in mind. 

Secondary Pneumonias. — Pneu- 
monias, mostly of the broncho-pneu- 
monic form, occur as complications of 
many diseases, and may in consequence 
be modified in their course and in the 
symptoms they present. Thus a miliary 
tuberculosis may give rise to an acute 

may run 
a short or protracted course, the two 




Fig. 30. —Temperature Chart of a case of acute 

lobar Pneumonia in an infant of 9 months; death broncho-pneumonia, WHl 
on third day. The whole left lung except a small 
part of upper lobe, which was emphysematous, 

was solid ; section of lung not so solid as red conditions present essentially modify- 
!S5^. , 2SS£*£ S ° me ° f " Pi ° k ing each other. In whooping cough. 

measles, scarlet fever, diphtheria, 
enteric fever, pneumonia may supervene caused by the specific micro- 
organism of the fever, or, in many cases at least, by the septic organisms 
present. While the pneumonia occurring in these diseases is usually of the 
broncho-pneumonic form, yet it is mostly fibrinous, and in the worst cases 
exhibits a tendency to pus formations, so that small purulent abscesses may 
be found post mortem. In some cases a true croupous pneumonia may 
occur. In diphtheria the pneumonia is often hemorrhagic, small patches 
of dark red extravasated blood being seen on section of the pneumonic lung. 



Broncho-pneumonia 2 1 / 

In acute summer diarrhoea a pneumonia is very apt to be present and 
add to the gravity of the attack ; in the chronic intestinal catarrh of 

infants the immediate cause of death is frequently an intercurrent attack of 
inflammation of the lungs. 

Chronic Broncho-pneumonia. — Attacks of broncho-pneumonia are apt 
to become chronic in consequence of an imperfect clearing up of the lung 
and the resulting caseous degeneration. Catarrhal pneumonia following; 
measles or whooping cough is very apt in an unhealthy child or one who 
inherits tubercular tendencies to take a subacute course ; a base or, less, 
often, an apex of a lung remains more or less dull, the breath sounds are- 
bronchial, moist sounds are heard, and the evening temperature rises to 102° 
or 103 F., with night sweats and emaciation. This state of things may go on 
for weeks, and it may be impossible to say if the caseous changes are pro- 
gressing or not. The risk in such cases is undoubtedly that, although the lung: 
may clear up, the bronchial glands may become caseous, and a general tuber- 
culosis of the lung, or perhaps tubercular meningitis, follow. Most cases of 
chronic broncho-pneumonia terminate either in recovery or tuberculosis., 
though in some instances they run a very chronic course resembling a chronic 
phthisis ; and at the post-mortem dilated bronchi and caseous and fibroid 
changes are found, but no tubercle, at least no grey granulations. Such cases 
during life are mostly regarded as chronic or fibroid phthisis : they present in 
their later stages the signs of consolidation of a portion of lung at an apex or 
base, the chest wall is probably retracted, there are bronchial breathing, sharp 
ringing rales, and very foetid expectoration, which is coughed up in large 
quantities. They are thin, anaemic, are easily put out of health, have clubbed 
fingers and dilated right hearts. They are usually very chronic cases. At 
the post-mortem there are found dilated bronchi filled with thick, foul secre- 
tion, cheesy nodules around the bronchial tubes, much fibroid and indurated 
lung tissue, and emphysema. In some cases there is gangrene of the lung; 
before death. Children liable to bronchitis, or who suffer from it in the chronic 
form, require to be warmly clothed and protected from cold. Residence in a 
warm climate and pure atmosphere during the winter, and at high altitudes 
during the summer, should be insisted on where possible. A warm house 
is necessary if they have to winter in this climate. Every means must be- 
employed which will improve their general health. In the following case a 
chronic pneumonia was followed by acute meningitis. 

Chronic Pneumonia. Acute Meningitis. — Rose S., aged 5 years. Child comes of a 
tubercular family ; has had acute pneumonia several times. She had acute pneumonia 
several weeks before admission, and was sent to the seaside. Admitted July 7, There 
is dullness on the left side behind, extending from the spine of the scapula to the base ; 
over this area there is weak bronchial breathing, and what is apparently redux crepitation. 
Temperature 101 . No albumen ; child well nourished, but pale. Temperature fell to 
normal during the next day or two. On July 15 the temperature suddenly rose to 104 F. 
Towards evening she began to vomit continuously ; temperature rose to 105° F, ; there 
were some preliminary twitchings, and then she was severely convulsed. The convulsions 
continued till early the next morning, when she died. 

Post-mortem. — Left lobe solid ; sinks in water; bronchi contain much purulent secre- 
tion, and their walls are thickened ; excess of fibrous tissue in the lung, spreading from 
the i-oot. Lung substance dark red, soft, and contains some small cavities sire of peas, 
containing thick, almost cheesy, pus. No obvious tubercle anywhere. brain, arachnoid 
everywhere cloudy, beneath it there is an excess of thud of a cloudv \ellow tint. 



2 1 8 Diseases of the Respiratory Apparatus 

- are matted with semi-purulent lymph. Base of brain much cloudy 
swelling beneath arachnoid. Xo tubercle anywhere. 

Prognosis. — Broncho-pneumonia is always a dangerous disease, but more 
-especially so in children under 2 years of age who are rickety or weakly. 
The prognosis is necessarily serious if the pneumonia follow any other dis- 
ease, as measles, whooping cough, or summer diarrhoea, or when it occurs in 
scarlet fever through the extension of the inflammatory process in the throat. 
In any severe case the danger depends upon the amount of lung involved 
and the softness of the chest walls. It must also be remembered that a young 
•child may struggle through the bronchial affection only to pass into a con- 
dition of atrophy — the result of a gastro-intestinal catarrh. Both high and 
also very low temperatures are indicative of danger. The pneumonia may 
l^ecome chronic and tuberculosis supervene. 

Morbid Anatomy. — The appearances seen post mortem in the bodies of 
•children dying of bronchitis and broncho-pneumonia are very various, and 
are apt to puzzle those unaccustomed to the autopsies made in children ; and 
much confusion has existed in the past in reference to them, especially in 
■confounding the various forms of pneumonia and carnification of the lung 
with collapse. Collapse of the lung is mostly patchy in its distribution, rarely 
affecting any continuous extent of lung or involving the whole thickness of a 
lung. It affects the anterior and inferior edges of the lungs, especially the 
anterior edge of the middle lobe of the right side and tongue of the left 
which covers the heart : it is sometimes present along the posterior border of 
the lung : the collapsed portions are depressed below the surface, purple in 
-colour, and airless. Taken between the finger and thumb, there is no sub- 
stance to be felt as in pneumonia. The collapsed portions can be inflated 
through the bronchi. The collapse is brought about in at least two ways — 
■either from occlusion of a small bronchus by thick mucus, the air being first 
imprisoned and then absorbed by the capillaries, or by feeble inspiratory 
power aided by obstruction to the entrance of air, especially when the ribs 
are soft, as in rickets ; in this case the chest falls in during inspiration, in- 
stead of the lungs becoming distended ; it is in this way that collapse is pro- 
duced along the anterior edges of the lung. The collapsed portions become 
cedematous from the stagnation of the circulation ; according to some, they 
become pneumonic. 

What happens to the collapsed portions of lung in the long run is not 
-clear. In most cases, apparently, recover}- takes place ; but we believe in 
some cases fibroid changes are set up, as evidenced by those chronic cases of 
"bronchitis and dilated tubes, the latter surrounded by indurated lung. Acute 
-emphysema plays an important part in the acute lung disease of children. 
It is sometimes produced very rapidly; thus, a child may die of acute broncho- 
pneumonia complicating measles in three or four days, and extensive emphy- 
sema may be present, no doubt produced during the period, and contributing 
very materially to the fatal result see p. 277 . The bases of the lungs are 
in an early stage of pneumonia and collapse, the upper lobes are overworked, 
the constant coughing consequent on the acute bronchitis produces emphy- 
sema, and the only remaining normal lung is thus damaged, and a fatal result 
quickly ensues. 

The chief types found maybe described shortly in the following groups : 



Broncho-pneumonia 2 1 9 

1. Acute Bronchitis involving the Smaller Tubes, Collapse of Lun^, 
Vicarious Emphysema. — On opening the chest the lungs are found to be in 
a condition of deep inspiration ; these surfaces are studded over with clusters 
of lobules which are depressed and purple in colour (collapse), and with raised 
portions which are of a pale pink colour (emphysema). On section, thick 
semi-purulent frothy mucus exudes from the large and small bronchi ; the 
latter sometimes contain a semi-membranous exudation. The cut surface of 
the lung exudes much blood-stained frothy fluid, due to congestion of the 
lung ; the lungs are crepitant, except where collapse has taken place. The 
large veins and right heart are much engorged. 

2. Disseminated Broncho-pneumonia. — The bronchial tubes contain 
much frothy fluid, one or both lungs, especially the lower lobes posteriorly, 
have a semi-solid feel, but crepitate, and perhaps some nodules of various 
sizes may be felt. The section exudes much serum, purulent mucus exudes 
from the small bronchi, the cut surface of the lung has a mottled appearance, 
caused by clusters of lobules, which are grey or pale pink and have a firm 
feel, and bright red portions of crepitant lung. The paler portions are pneu- 
monic and solid ; the red portions are air-containing congested lung, which 
surround the pneumonic portions. Portions of lung which are removed will 
float in water, but easily break down on thrusting in the finger. The upper 
lobes are emphysematous. 

3. Acute Generalised Broncho-pneumonia, Pleurisy. — The posterior 
inferior or whole of one or both lobes has a semi-solid feel, though less solid 
than in croupous pneumonia, with>.but little or no sense of crepitation. The 
surface is purplish in colour ; the pleural covering may have minute haemor- 
rhages on its surface, or be roughened from the presence of lymph. The cut 
section has a solid feel, yet it is not granular as in true croupous pneumonia, 
but easily breaks down on pressure with the finger, and sinks in water. It 
has a mottled appearance, in consequence of the lobules surrounding the ter- 
minal bronchi being paler in colour and in a later stage of consolidation 
than the intervening portions of lung. There will probably be collapse 
of the anterior and inferior edges, as well as acute emphysema in the 
same positions ; some of the vesicles are frequently distended to the size of 
millet seeds, or even peas, and perhaps one here and there is ruptured. In 
a still later stage, especially if the inflammation is intense, as in measles or 
scarlet fever, a lobe may be solid, and on the surface beneath the pleura 
there are a number of yellow spots, the size of millet seeds or larger, which 
on pricking yield a drop of thick pus. On section, these yellow spots are seen 
scattered through the lung ; they are the ' graines jaunes,' or ' abces peri- 
bronchique,' of French authors, and are, in fact, minute abscesses surrounding 
the terminal bronchioles, formed by the softening of the pneumonic lobules. 
Pleurisy with lymph or serum maybe present ; when the pneumonia is double 
the temperature usually runs high. 

The following case illustrates this form of pneumonia : 

Acute Double Pleuro-pneumonia, Hyperpyrexia^ Suspicion of Meningitis. — John 11., 
aged 14 months; admitted April 26, 1894. His mother states he has been .1 healthy child 
up to the present illness. A fortnightago he became ill with cough and fever. Breathing 
has been very bad at nights. IK- vomits frequently. He is fairly well nourished; his 
head is somewhat retracted, and muscles of the nock are rigid. The right apex in front 



220 Diseases of the Respiratory Apparatus 

and the base behind are very dull ; bronchial breathing and sharp crepitation are heard over 
this area. On the left side there are rales, but no dullness ; gij of clear serum were with- 
drawn from the right side behind. Temperature 103 . Vomits constantly. April 27. — 
General convulsions, mostly right-sided ; marked rigidity of the neck ; vomits constantly. 
Well-marked tache ce'rebrale. April 28. — Very short breathing ; dullness well marked at 
the left base as well as the right. Oxygen given. Temperature 106 . Graduated bath. 
April 29. — Marked retraction of the neck; constant vomiting. Temperature 106 •4 . 
April 29. — Temperature 106-4° twice during the day. Death May i. 

Post-mortem. — Right pleural cavity contains sj of yellow serum, and lymph covering 
the lower lobe, which is partly compressed and partly solid ; upper lobe solid at the back, 
showing broncho-pneumonia and emphysema in front ; lower lobe, lymph on surface,, 
pneumonia on section. Much clear fluid escaped from surface of the brain and lateral 
ventricles ; no lymph anywhere. Arachnoid cloudy ; veins full. It was suggested that 
the infant had meningitis complicating the pneumonia, but this was not borne out by the 
autopsy. 

4. In infants under 6 months a form of pneumonia is sometimes 
found which does not agree with the above description. A lobe, generally- 
one of the lower, is semi-solid, its surface depressed and purple, surrounded,, 
perhaps, by raised emphysematous vesicles. The cut section is smooth and 
of a uniform plum colour, the lobules indistinct and airless, but the lung has 
not the solid feel of red hepatisation. 

5. In some cases nodules of fibrinous pneumonia as large as hazel nuts 
or walnuts, hard, and with a granular surface, may be found. We have seen 
this condition in connection with measles. 

It has already been remarked that clinically broncho-pneumonia some- 
times so closely simulates croupous pneumonia that it is difficult to say to 
which variety it is to be referred. The same difficulty may occur in the 
Post-mortem room, as some lobular pneumonias have almost the solid feel 
found in croupous pneumonia, and a microscopic examination shows the 
air vesicles to contain fibrin, and yet the section, to the naked eye, is not 
granular as it is in red hepatisation, but mottled, the clusters of lobules 
varying in tint, and more closely resembling in appearance the condition of 
broncho-pneumonia. 

The micro -organisms present in the broncho-pneumonia occurring" 
in children have been studied by recent observers, more especially by 
Neumann, 1 Queisner, 2 Strelitz, 3 and Prudden and Northrup. The commonest 
micro-organism found appears to be the Frankel-Weichselbaum diplococcus,, 
much less often Friedlander's bacillus. In the septic pneumonias present 
in scarlet fever, measles, and diphtheria various micrococci — including; 
Stapholy coccus pyoge?tes aureus and al&us, and Streptococcus Pyogenes — are 
usually present. 

In the present state of our knowledge it is unwise to lay too much stress, 
on the presence of these organisms in the pneumonic lungs ; but it seems 
exceedingly probable that there are several micro-organisms which, if the 
conditions are favourable, are capable of giving rise to inflammation of the 
lungs. 

Diagnosis. — A clinical distinction between the above conditions is often 
impossible, inasmuch as bronchitis, collapse, emphysema, and catarrhal. 

1 Jahrbuch Kindcrh. Band xxx. p. 233. 2 Loc. cit. Band xxx. p. 277. 

5 Archiz' f. Kindcrh. Band xiii. p. 468. 



Broncho-pneumonia 221 

pneumonia may all exist in the same lung, and more or less mask one 
another. However, a few points may be emphasised. In simple bronchitis 
the temperature is rarely high, there is no impairment of resonance, and the 
moist sounds, if present, are indistinct and distant. In broncho-pneumonia 
the temperature is higher, usually there is impaired resonance, perhaps 
whiffy or bronchial breathing, and the moist sounds are clear, sharp, and 
ringing. The diagnosis of collapse is much more uncertain unless much 
lung is involved ; then there are impaired resonance and weak and distant 
bronchial sounds. 

In all cases of broncho-pneumonia we must bear in mind the possibility 
of some localised collection of pus being present over a dull patch, and also 
that the case may be one of miliary tubercle as well as broncho-pneumonia. 
Treatment. — The colds in the head and bronchial catarrhs of children 
call rather for careful hygiene than active treatment. Confinement to a well 
warmed and ventilated room or suite of rooms, as long as the symptoms of 
a cold are present or rhonchi are heard in the chest, with a light, mostly fluid 
diet, will in many cases be all that is necessary. Merely to confine a child 
to the house and let it run about in cold passages and stand in draughts is 
useless, and likely to give rise to another cold before the first has completely 
passed away. Some children are exceedingly liable to take cold, and bron- 
chitis follows very readily, and with these extra care must be taken, and the 
last trace of a cold must have disappeared before they are permitted to go 
out. In those cases where there is a laryngeal or tracheal catarrh the cough is 
often troublesome, especially keeping the patient awake at night and disturb- 
ing the whole household. Among the household remedies for coughs which 
are useful are black currant jelly, glycerine lozenges, liquorice, and jujubes 
simple or medicated. A cup of hot beef tea or cocoa the last thing at night 
will often soothe a troublesome cough. In many cases it will be necessary 
to give small doses of some sedative, especially in the case of older children. 
Morphia, codeia, aconite, hyoscyamus, bromide of ammonium, may be given 
for this purpose, made up in the form of a linctus with syrup of orange or 
tolu or glycerine. The morphia and ipecacuanha lozenges of the B.P. made 
with fruit paste or glycerine jelly are very convenient. Codeia jelly acts 
exceedingly well in soothing irritable coughs. 

The diet should consist largely of fluids, milk, beef tea, light puddings. 
Lemonade, barley water, linseed tea, to assuage thirst and tend to produce 
free action of the kidneys and skin, are likely to be useful ; salines such as 
citrate of ammonia or potash, or liq. amnion, acet, may also be given. 

The prevention of attacks of bronchial catarrh and colds is a matter of 
much importance, especially in the case of those who are liable to bronchitis 
or asthmatic attacks whenever they take cold. A house in a dry and bracing 
situation, with well-warmed living rooms, passages, and bedrooms while 
the ventilation and sanitation are carefully looked after— is a first necessity 
in the prevention of colds. Care must be taken that such children are 
properly clothed with well-fitting woollen under-garments, that they have 
plenty of exercise in the open air whenever the weather is suitable, while cold 
sponging or the tepid douche in the morning whilst standing in warm water is 
of much service in promoting the circulation in the skin and preventing chills. 

Are 'colds in the head' infectious? It is a common experience thai 



222 Diseases of the Respiratory Apparatus 

almost a whole household is affected at the same time or in succession, and 
there can be little doubt that in some cases a nasal catarrh passes from one- 
child to another without the latter having been exposed to any chill. Other 
conditions favouring these attacks may be present, but of these next to 
nothing is known. Possibly a chill may predispose the mucous membrane 
to take on inflammation or become a suitable nidus for the cultivation of 
bacilli or other organisms present in the atmosphere. 

If the catarrh passes downwards from the trachea into the smaller tubes, 
and the child in consequence ' wheezes ' and rhonchi are heard all over the 
chest, the child should be confined to its bed or cot, care being taken to have 
it warmly clothed and in a situation free from draughts. In the more severe 
cases of bronchitis and catarrhal pneumonia, especially in small children, a 
sort of tent should be rigged over the cot, or one or two clothes screens placed 
around with sheets hung on them so as to form sides and a roof will answer 
very well. The atmosphere must be kept moist by means of a bronchitis 
kettle, or the sheets which form the walls of the tent may be kept moist. 
The temperature in the cot should be maintained at 65°-70° night and 
day. The diet should consist entirely of fluids if the attack is at all acute. 
Milk diluted with one-third or one-fourth part of whey, barley water, or soda, 
water should form the principal kind of nourishment ; a cup of beef tea 
once or twice a day may be allowed. Moist, hot applications to the chest 
are soothing to the patient, and may be applied in the form of linseed poultices 
or fomentations. It must, however, be borne in mind that poultices made by 
unskilled hands may, especially in the case of infants and young children, 
do more harm than good ; to surround the chest of an infant with a heavy 
poultice when the bronchial tubes are choked with thick mucus and patches 
of lung are in a state of collapse is simply to invite death by suffocation. The 
poultices should be well mixed, being not too heavy nor applied too hot 
(placing them against one's cheek is the best guide), carefully kept in position 
by means of a flannel binder, and renewed at least every four hours. A 
mustard poultice is often of great service in the early stage ; one tablespoonful 
of mustard to four or five tablespoonfuls of linseed meal may be used, the 
poultice remaining on for three or four hours. This strength is not sufficient to 
produce more than some redness, and it can be renewed or replaced by a 
simple poultice according to circumstances. For infants and young children 
hot fomentations applied by means of spongio-piline or flannel are preferable 
to poultices : they are much more cleanly, and harm is less likely to be done 
by their application. Several layers of flannel may be used wrung out of 
water, or if need be mustard and water, and covered with a piece of oiled 
silk, the whole being surrounded by cotton wool. Poultices and hot applica- 
tions are of most service in the early stages, when the mucous membrane is 
swollen and dry and the secretion scanty ; in the later stages they are also 
useful if the secretion is thick and coughed up with difficulty. 

In the early stage of bronchitis, if there is much wheezing, dyspnoea, and 
distress, an emetic is of much service, more so, perhaps, in bronchitis than in 
catarrhal pneumonia. Pulv. ipecac, in 5 -grain doses in syrup of orange 
peel may be given to a child under 2 years of age and repeated in a few 
minutes if it fail to act. The act of vomiting, especially after ipecacuanha, 
will probably be attended by a freer secretion of mucus and relief to the 



BroncJw-pneumonia 223 

breathing. At this period the depressant expectorants which appear to 
diminish tension in the vessels and thus relieve the congested mucous 
membrane are mostly used. Of these antimony, ipecac, and aconite are 
more frequently used than any others. In this stage, when the cough is 
hard and sibilus is heard in the chest, antimony in small repeated doses^. 
short of producing nausea and depression, is of much service. (F. 23.; 

In catarrhal pneumonia aconite in half-minim or minim doses is preferable. 
The drug may be continued for several days, as long as the fever lasts or 
the secretion remains scanty or is coughed up with difficulty. Given with 
caution and in small doses there is little fear of its producing too great de- 
pression ; in feeble children, however, it may be well to give small doses of 
alcohol at the same time. Many prefer to give ipecac, or, instead of aconite, 
antimony, especially in the feeble and cachectic patients so often met with in 
the out-patient room. Some believe ipecac, combined with alkalies such as 
bicarbonate of potash to be of especial value when mucous rales are heard 
in the chest, and the infant or child has much difficulty in coughing up 
the thick secretion which is formed. Simple salines are preferred by some. 
Dr. Lewis Smith recommends tr. veratri viridis in half-minim or minim doses 
every second hour. As long as the cough remains hard, and the mucous secre- 
tion scanty or difficult to expel, the antimony or ipecac, should be persevered, 
with, and is far more likely to be of service than the stimulating mixtures so 
often prescribed. It is when the catarrh continues, the cough becoming 
loose, the secretion liquid, and the fever is mostly gone, that carbonate of 
ammonia, squills, and terebene are most likely to be useful. At this stage 
the fomentations and poultices should be given up in favour of a warm 
cotton-wool jacket, and stimulating applications may be applied to the chest 
walls. Ammonia may be usefully combined with digitalis and squills, as in 
F. 24. 

Stimulating applications to be rubbed into the chest-wall are useful in 
producing slight redness without being too severe. (F. 25, F. 26, F. 27.) 

The lin. potass, iodidi c sapone B.P. may be used in a similar way. 

Iodide of potassium is often useful in the subacute or chronic stage, and 
nitric acid and nux vomica are of much service during convalescence. 

In bronchitis pure and simple the temperature is never so excessive as to 
require any antipyretic treatment, but in some cases of acute broncho-pneu- 
monia, especially where it approaches the croupous type, or when it accom- 
panies whooping cough or measles, the temperature is apt to take high flights. 
Sponging with tepid water, ' packs,' or when there is drowsiness or con- 
vulsions the warm bath gradually cooled down by adding cold water so as 
to reduce it to 6o°, may be used. Phenacctin or antipyrin may lie used for 
the same purpose with care, beginning with a small dose, 2 grains o\ the 
former for a child of 2 or 3 years of age. Both of these antipyretics ha\ e 
been used in small doses frequently repeated, in acute bronchitis and in 
broncho-pneumonia. An excessively high temperature, 104" [05 , is some- 
times present in an early stage of pneumonia, accompanied by convulsions 
or coma ; in such cases no time should be lost in resorting to baths or packs, 
while giving stimulants if necessary by the rectum. 

Death usually threatens in bronchitis or broncho-pneumonia from 
mechanical interference with the air entering the lungs, asphyxia being pro- 



224 Diseases of the Respiratory Apparatus 

duced, with great depression of the hearts action. This occurs, especially in 
young infants, by a blockage of the medium-sized and small tubes by thick 
mucus which is difficult to expel, or is due to capillary obstruction, collapse 
of lung, acute emphysema, or a large tract of lung becoming involved in the 
pneumonic process. In young infants with obstructed bronchial tubes all 
tight binding up of the chest walls by poultices or bandages must be 
avoided ; the position must be varied from time to time so as to give each 
lung full play in turn, and an occasional emetic of alum or squills will help 
to get rid of the excessive and tenacious secretion. The nurse's finger may 
oe usefully employed in removing the secretion from the back of the 
throat after a fit of coughing. In suddenly produced dyspnoea either from 
collapse of lung or acute pneumonia, when the circulation through the lungs 
is obstructed and the right heart over-distended, local bleeding by means of 
a leech or two is often of the greatest service, and may be the means of 
•saving life. One, two, or three leeches may be applied at the tip of the 
sternum, and after they fall off the bleeding may if necessary be encouraged 
"by warm applications. [Mustard baths, or mustard fomentations, or 
turpentine stupes applied to the chest, are likely to be useful in those cases 
where there is extensive pneumonia with much dyspnoea and cardiac 
•depression— turpentine must be used cautiously. Ammonia and digitalis 
must also be freely given under similar circumstances. Oxygen inhalation 
may be resorted to, but we cannot say that we have had much success with it. 

The question of the administration of emetics, alcohol, and opium, is of 
importance. Emetics are mostly of value in the early stages of laryngitis or 
"bronchitis when the cough is hard and the breathing difficult on account of 
the swollen condition of the mucous membrane ; a freer secretion follows the 
administration, and, moreover, the unloading of the stomach of the accumu- 
lated mucus and undigested food seems to have a good effect ; ipecacuanha 
or sulphate of zinc answers best at this stage. Emetics are sometimes 
useful in a later stage of bronchitis and collapse when the bronchial tubes 
are choked with mucus, provided there is no pneumonia or cyanosis : 10 to 
30 grains of alum in a teaspoonful of syrup of squills is 'preferable to 
ipecac, or zinc at this time. Alum and honey may be given to infants on a 
small brush. Alcohol is unnecessary in the early stages, and it should 
always be used with caution in the later stages, for. like opium, it soothes 
the cough and in large quantities its effect is narcotic ; it is therefore 
contra-indicated except in small doses if there is any tendency to cyanosis. 
Opium in the form of Dover's powder is often of great value if the child is 
restless and its cough irritable, but it is perhaps needless to say it should on 
no account be given if there is much dyspnoea due to the accumulation of 
mucus in the bronchial tubes or if much lung is involved. 

During an acute attack of bronchitis or pneumonia the digestive organs 
are very apt to suffer ; there may be vomiting, flatulence, and diarrhoea. 
This impaired digestion must always be borne in mind when the question of 
dieting is being discussed, and care must be taken not to overload the stomach 
and bowels with too large a quantity of milk, beef tea, &c. An occasional 
laxative dose of calomel or rhubarb and soda may be useful. 

It is well to bear in mind the possibility that an infant may recover from 
an acute attack of bronchitis, to finally succumb to a gastro-intestinal atrophy 
■ dating: from the acute bronchial attack. 



Croupous Pneumonia 



225 



Croupous Pneumonia 



Croupous pneumonia in its typical form is a common disease in children 
-over three years of age, and docs not differ either in its course or morbid 
anatomy from the attacks in young adults, though the mortality is much 
less. Reference has already been made to the acute lobar pneumonias of 
infancy and childhood, which are frequently classed amongst the fibrinous or 
genuine croupous pneumonias on account of the extent of lung involved and 
also of their termination by crisis. That many of them are fibrinous to some 
extent is certain, as effused fibrin may be seen in sections prepared for the 
microscope, but in our experience such lungs when seen on the post-mortem 
table are more spongy and lack the complete solidity of the red hepatisation 
of true croupous pneumonia, and the outlines of the lobules are readily seen 
in consequence of their differing from one another as to the extent to which 
they are affected. Moreover, while they may contain fibrin, the cellular 
element largely predominates. Fortunately it is of little practical moment 
under which division these pneumonias are classed : hybrid cases are certain 
to come under observation both in infancy and childhood, and we have 
frequently to be content with describing attacks as being of the ' croupous 
type,' or of the ' catarrhal' or 'broncho-pneumonic' type, according as their 
symptoms resemble typical attacks of either the one or the other. It is the 
difficulty of classifying hybrid cases that makes the statistics of one hospital 
or one year liable to error when compared with that of other hospitals or 
years. 

The statistics (given below) of our own hospital of the cases entered as 
croupous pneumonia during the years 1878- 1893 illustrate the comparative 
frequency of the disease at different ages. In this series of cases the total 
mortality amounted to 5-2 per cent., the highest being among children under 
2 years of age. ' 

Table showing tJie Ages and Mortality of 708 Cases of 
Croupous Pneumonia 



Under 2 yea 



2 to 5 years 



29 



21 



Total Deaths I Total Deaths Total Deaths 



338 



years 


\o to 14 years 










Total 


Deaths 


Deaths 


Total Deaths 






8 


128 I 


70S 


3$ 



The etiology of croupous pneumonia is not perhaps quite as simple as it 
seems at first sight. A schoolboy is exposed to a cold oast wind after 
getting hot, or is chilled by a fall into water, and a few days later develops 
an acute pneumonia: in such cases there can be little doubt that pneumonia 
in some way or other is the result of a chill. In connection, however, with 
this, our own hospital statistics do not show much difference in the number 
of cases admitted during the different mouths of the year, though there is a 



• 1 nose 

aroupous 



ngures cioseiy corn 
pneumonia in chil< 



jpon< 

Oil u 



th ti 



iven by Von 1 )usch ; in 
of age the mortality wi 



31 of his cases 
4*8 per cent. 



226 Diseases of the Respiratory Apparatus 

slight preponderance in favour of March. 1 Attacks certainly occur at all 
times of year, in the wanner as well as in the colder months. On the other 
hand, it is quite certain that croupous pneumonia is at times epidemic and 
also infectious, affecting several members of the same household or the same 
street, and in a few instances there have been widespread epidemics, as, for 
instance, during the influenza epidemic of 189 1. Epidemics of pneumonia 
associated with tonsillitis have occurred in schools and other large institutions 
where the sanitary arrangements have been found faulty. It may be taken 
for certain that while there is a form of pneumonia of the croupous type 
which follows a chill, it may be produced by other causes, such as infection by 
the inhalation of the Frankel-YVeichselbaum diplococcus or the influenza 
bacillus, or it may be part of some general septic poisoning. In some 
instances acute pneumonia has followed injury ; a blow on the chest or a 
fall on the head has been followed a few days later by a pneumonic attack. 

It seems to us that it is more than probable that these micro-organisms 
are incapable of setting up pneumonia in healthy lung in a normal condition ; 
but if the individual has caught cold or is in a low state of health a suitable 
soil is produced, and if an infection take place a pneumonia is the result. 

The pneumonic diplococcus appears to be almost constantly present in 
the sputa of cases of croupous pneumonia in the early stage, but it is also 
found in the pus from an acute otitis and also in the effusion in cerebro- 
spinal meningitis. It has been found in the sputa of healthy children. It 
can hardly be said to be pathogenic of pneumonia, but it is apparently 
capable of setting up pneumonia under certain conditions. 

In different epidemics, or in different years or localities, attacks of 
pneumonia appear to van- in their character, sometimes being of the 
sthenic, sometimes of asthenic type ; this has been specially described by 
FoxwelL 2 

Symptoms and Course. — The onset is sudden, with symptoms not unlike 
those of scarlet fever : there is high fever, dyspnoea, rapid pulse, headache, 
pain in the side or abdomen, short cough, and perhaps vomiting and 
diarrhoea. In children under three years convulsions are not uncommon at 
the onset, but these are rare in older children : the convulsions may prove 
fatal before the attack of pneumonia has fully declared itself. Delirium may 
be an early symptom, especially if the fever is high. By the time a medical 
examination is made the child is usually too ill to be about, and is either in 
bed or being nursed in its mother's arms ; the cheeks are flushed, the afe 
nasi are working, the respirations are perhaps doubled, being possibly 40 
per minute or more, the pulse 120 to 140, there is a temperature of 104° or 
thereabouts, the tongue is dry and brown, and there may be herpetic vesicles 
on the lips and nose. An examination of the urine shows it to be dark in 
colour, concentrated, containing albumen and an excess of urea, and deficient 
in chlorides. The cough is dry and hacking, and pain is often complained of 
during the act : in young children there is no expectoration, in older ones 
there may be the usual rusty sputa. The fever and dyspnoea continue, the 
child remaining very ill till the end of the week, when, usually between the 

1 In 628 cases of croupous pneumonia during the years 1857-1885. Durasz found a 
slight excess in April and May. 
- Practitioner, July 1886. 



Croupous Pneumonia 227 

sixth and ninth day, the fever suddenly abates, and a marked improvement 
takes place in all the symptoms, so that it is evident to all that the crisis has 
come. The crisis is sometimes marked by collapse, the child becoming cold 
and clammy, with a subnormal temperature. 

Physical Signs. — An examination of the chest on the first or second day 
of the attack will usually lead to the discovery of more or less consolidated 
lung. Careful percussion, striking now lightly, now more forcibly, will elicit 
a certain high-pitched note of impaired resonance over some part of the 
chest wall, as in the infra-clavicular, axillary, or scapular region, or over the 
root or base of the lungs ; on listening over the affected area some departure 
from the normal breath sounds will probably be heard. There may be 
simply weak or distant breathing, as if the air was not entering freely into 
some part of the lung ; there may be distant or intense bronchial breathing, 
or various abnormal sounds, as a pleuritic rub, rhonchus, or, more often, 
subcrepitant or loose ringing rales, the fine crepitation so common in adults 
being generally absent. There are usually increased vocal resonance and 
fremitus, though it is not always possible to elicit these signs unless the child 
cries. If there is much lung affected, loud or harsh breath sounds are heard 
over the non-affected lung, and care must be taken not to mistake these signs 
of an overworked, for those of an affected lung. 

The position of the consolidation varies considerably and does not 
necessarily correspond to a lobe, but may occupy the whole extent of lung 
anteriorly or posteriorly ; or the most marked signs maybe first detected over 
the root of the lung behind or in the axilla. The left base and right apex are 
favourite spots to be attacked, but any part of the lung may be involved, 
though it must be borne in mind that the apices are more apt to be affected 
in children than in adults, and it is just at this spot that early signs are apt to 
be overlooked. In the course of a day or two, sometimes not for several, the 
physical signs become more marked, the dullness cannot be mistaken, the 
bronchial breathing becomes whiffy and intense ; in a few days more, usually 
after the crisis has arrived, coarse loose crepitant rales are heard which 
mark the resolution of the pneumonic lung. The dullness and bronchial 
breath sounds and rales disappear, but some want of resonance is apt to 
remain for many weeks, as the lung remains in an cedematous state. While 
such is the usual course of events in an ordinary case, there are marked 
differences with regard to the time when the physical signs make their appear- 
ance, there being frequently a delay of several days ; they ma}- even appear 
as late as the fifth day. It is important to remember this, for a mistake in 
diagnosis is easy, as a most careful examination of the whole chest may reveal 
nothing suggestive of pneumonia. In such cases there is a strong presump- 
tion that the pneumonia is centrally situated, perhaps at the root o\ the 
lung, and takes some time to approach the surface ; or possibly there may 
be an acute inflammatory congestion of a portion of lung and a delay in the 
transudation of fibrin into the air sacs. Often a sub-tympanitic or actually a 
tympanitic note to percussion and weak bronchial breathing, or simply 
distant respiratory sounds, may be all there is to be heard (or a da) or two. 
It is not easy to say why a tympanitic or 'boxy' note is elicited over lung 
in a state of acute inflammatory congestion, or in the first stage of a\\ acute 
lobar pneumonia, but that it do?s occur we have often had the opportunity 



228 Diseases of the Respiratory Apparatus 

of observing. In a few cases the crisis may come and the child recover 
without the classical signs of pneumonia ever being present. 

Temperature. — The temperature usually goes up suddenly at the onset 
to 104 or thereabouts, and during the course 'of the attack continues high, 
with slight morning remissions, till the crisis, when the fall is sudden (see 
%• 30> perhaps 4 or 5°, to a subnormal temperature ; the latter may last for a 
few days, and then the normal line be regained. The day on which the crisis 
takes place varies greatly ; the attack may end about the fourth or fifth day 
or earlier, but usually the crisis is delayed till the seventh or eighth, and in 
the creeping form till the end of the second week or later ; a post-crisial 




f --'• 3 1 - — Temperature Chart of a case of Croupous Pneumonia of left apex in a girl of live years. 
Crisis sixth day. Recovery. 

rise often occurs (see fig. 32), the temperature rising a few degrees the fol- 
lowing evening, becoming normal the next morning ; or a relapse in which 
the temperature remains elevated may take place in consequence of another 
portion of lung being affected. Post-crisial hectic, prolonged for some days 
or weeks, suggests the presence of an empyema or other complication. In 
the minority of cases the temperature falls by lysis. 

Varieties. — The course of the attack varies ; these varieties have been 
emphasised by various writers, especially by A. Baginsky ; they may be 
enumerated as follows : (1) Abortive Pneumonia.— This variety, as the 
name applies, aborts, or the course comes to a sudden termination by crisis, 
after lasting two, three, or four davs, mostlv without the classical signs of 






Croupous Pneumonia 229 

pneumonia being developed ; yet a careful examination of the lungs will 
discover some spot where the breath sounds are weak and the percussion 
note slightly raised or tympanitic. Herpes is common on the lips and 
nose. (2) Creeping or wandering Pneumonia has been compared b) 
Henoch to an attack of erysipelas spreading over the surface of the lung 
The apex is perhaps the first part affected ; gradually the inflammaton 
process spreads to the base, and possibly finally attacks the opposite side. 
Such cases are apt to have a chronic course, the crisis being delayed till the 
tenth or fourteenth day, or the temperature may fall by lysis, or a hectic ma\ 
succeed in consequence of an empyema being present. (3) Relapsing 




Fig. 32. —Temperature Chart of a case of Croupous Pneumonia of left Lung in a girl of live years, 
treated by cold baths. Crisis fourth day ; post-cri&ial rise. Recovery. 



Pneumonia much resembles the creeping form. Several relapses occur 
after the crisis has come, some patch of pneumonia occurring in another 
part of the lung. We have known cases in which six or seven relapses have 
occurred. In such cases we may suspect pus. (4) Cerebral Pneumonia. 
In this form cerebral symptoms are prominent, while, in the early stag< 
least, the symptoms of pneumonia are latent; there may be convulsions, 
delirium, headache, and drowsiness. In such eases the fever usually runs 
high, and the cerebral symptoms maybe due to the high fever and poisoned 
blood. Not Ullfrequently the lesion in these eases is at the apex. Cough i-> 
often absent. (5) Gastric Pneumonia. In these cases gastric symptoms 
are most marked; the attack may begin with vomiting, diarrhoea, coated 



230 Diseases of the Respiratory Apparatus 

tongue, fever, and abdominal pain, and it is only after a day or two, when 
the classical signs appear, that a diagnosis of pneumonia is made. The 
attack may simulate gastro-intestinal catarrh or peritonitis, the abdo- 
minal pain being due to diaphragmatic or costal pleurisy. (6) Pleuro- 
pneumonia. — In these cases the signs of pleurisy predominate ; there is 
sharp stabbing pain, tenderness on percussion, and the child screams when 
it coughs or turns over in bed. Signs of consolidation are succeeded by 
those of pleuritic effusion, or an empyema possibly results. 

Complications and Seguetcz.— "Pleurisy frequently accompanies croupous 
pneumonia ; percussion over the dull area and deep pressure give pain, and 
friction sounds are frequently heard ; the pleurisy is apt to become suppura- 
tive in weakly children, especially if the pneumonia occurs in the course of 
scarlet fever, measles, or whooping cough (see infra). Pericarditis some- 
times occurs. Hyperpyrexia, a temperature of 105 or 106 occasionally 
taking place, accompanied by cerebral symptoms, convulsions in young- 
children, or stupor and delirium in older ones. Meningitis is rare, though it 
occurs occasionally simultaneously with the pneumonia or follows as a sequela, 
being most common in young children. Nephritis also occurs in associa- 
tion with pneumonia ; usually the latter is secondary to the former. Jaundice 
sometimes accompanies pneumonia, especially of the right base (see p. 232). 
Gangrene of the lung- occasionally supervenes and brings about a fatal 
result ; this seems mostly to occur either in pneumonia secondary to neph- 
ritis, or when pneumonia occurs in a subject who has emphysematous lungs. 
The possibility of the lung being adherent to the chest and undergoing an 
indurating or fibroid process must be kept in mind. A chronic condition of 
caseation may remain , but this is much commoner after catarrhal than after 
croupous pneumonia. Diphtheria of the fauces may complicate it ; once 
or twice we have discovered, to our surprise, late in the attack or on the 
post-mortem table, false membrane on the fauces. 

.; Prognosis. — The prognosis is favourable in cases of croupous pneumonia 
when it is primary and attacks healthy children over three years of age ; 
among such the mortality is small. Double pneumonia is necessarily more 
fatal than single, but here the amount of lung involved at one time is not 
necessarily great, as usually while it is advancing on one side it is receding 
on the other ; the danger depends on the amount of lung involved, and the 
respirations give a more or less useful indication of this. In a child who 
already suffers from chronic bronchitis and emphysema or cardiac disease, 
the prognosis is much worse. Secondary pneumonia, when it follows or 
complicates scarlet fever, measles, whooping cough, nephritis, or follows 
operations or is connected with septicaemia, is necessarily a serious and often 
fatal disease. When much pleurisy accompanies the pneumonia, especially 
in young children, the prognosis is less favourable than in cases of simple 
croupous pneumonia. 

Diagnosis. — In those cases of croupous pneumonia which begin with 
vomiting and high fever, and where the physical signs are delayed, there is 
a certain superficial resemblance to scarlet fever. That such cases are liable 
to be mistaken for scarlet fever is shown by the fact that not uncommonly 
cases of acute pneumonia are sent into fever hospitals certified as suffering 
from scarlet fever. A careful examination of the patient, and, if necessary, a 



Croupous Pneumonia 231 

delay of twenty-four hours before coming - to a decision, will, in the large 
majority of cases, prevent such an error. In the first twenty-four hours in a 
sharp attack of scarlet fever there may be high temperature, vomiting, diar- 
rhoea, rapid pulse (often 150), tonsillitis more or less developed, no pain in 
the chest, or cough. The rash usually appears at the end of twenty-four hours, 
in acute pneumonia there may be high fever, headache, pain in the chest or 
abdomen, dyspnoea, pulse perhaps of 120, perhaps some physical signs in 
the chest, not often vomiting, diarrhoea, or tonsillitis. There is no rash. 
Acute pneumonia with marked cerebral symptoms such as delirium, stupor, 
or headache, sordes on the teeth, and high fever may be taken for typhus. A 
careful examination of the lungs would generally decide ; in typhus there may 
be evidence of bronchitis ; in pneumonia there would usually be some want 
of resonance at an apex or base, with some distant or bronchial breathing. 
The presence of a characteristic rash on the third or fourth day would decide 
the diagnosis ; it is well to remember that in children typhus is usually a mild 
disease. In young children an acute attack of croupous pneumonia, with 
high fever, convulsions, drowsiness, or coma, may be mistaken for acute 
meningitis, or, as a matter of fact, pneumonia and meningitis may co-exist. 
We should, however, hesitate in the presence of pneumonia and a temperature 
of 104 or 10 5 to diagnose meningitis, the cerebral symptoms being due to 
the high temperature and poisoned blood. In all cases where a young child 
is suddenly taken with convulsions and high fever, pneumonia should be sus- 
pected and a careful examination of the lungs made. We must remember 
that the temperature may be high, 104 or 105 , as the result of only a small 
patch of pneumonia. In such cases, especially in infants, the pneumonia may 
be overlooked and the temperature be attributed to teething. The diagnosis 
between croupous pneumonia and generalised broncho-pneumonia may not 
be easy during life ; we cannot often do more than say such and such an 
attack approaches more nearly to the croupous type, when there is a sudden 
•onset, a local portion of lung involved, a continuous temperature, and a crisis ; 
that it is more of the catarrhal type when there is much bronchitis, an inter- 
mittent temperature, and gradual subsidence of the fever. The difficulty does 
not always end in the post-mortem room, as typical fibrinous pneumonia 
in patches or more widely distributed may be found in one lung and un- 
doubted lobular pneumonia in the other, while both varieties may be present 
in the same lung. 

Pathology. — In croupous pneumonia the first stage is that of an inflam- 
matory engorgement of an extended portion of lung, the vessels are full, the 
capillaries are tortuous and distended, encroaching on the air space in the 
sacs ; in the second stage the engorged vessels relieve themselves by pouring 
out liquor sanguinis and some corpuscular elements into the air sacs, which 
become blocked with fibrine, and a condition of red hepatisation resi 
This red hepatisation, when seen at the post-mortem, differs from the lobar 
variety of catarrhal pneumonia in that it is more solid to the touch, and 
presents a uniformly coloured surface on which the outlines of the lobules 
cannot be distinguished ; in children it is less often granular than it is in 
adults. In a later stage grey hepatisation is found, the lighter colour b< 
due to the presence of a greater number of corpuscular elements. In lung 
m a state of red hepatisation, Krankel-Weichselbaum diplococci may he 



232 Diseases of the Respiratory Apparatus 

usually detected by Gram's method. In one of our recent cases of fatal 
croupous pneumonia, in a boy of four years of age, who died on the eighth 
day (having been deeply jaundiced for three or four days), the left lung was 
in a condition of red and grey hepatisation, except at the extreme apex. 
There were some localised hepatised patches in the right base We were 
able to obtain cultivations on glycerine agar of the Frankel-W. diplococcus, 
Staphylo-coccus ftyog. m/reits, and Strepto-coc. pyoge?ies. 

Treatme?it. — An uncomplicated case of croupous pneumonia in a child does 
not require active treatment, as the course is short, and the heart and arterial 
system, unlike the condition often found in adults, are free from degenera- 
tions, and able to stand the strain imposed upon them. The child should, of 
course, be confined to his bed in a well warmed and ventilated room ; he should 
be allowed only fluid nourishment, such as milk, barley water, and soda water. 
A piece of spongio-piline or flannel doubled several times may be wrung out 
of hot water, and applied to the chest. Poultices may be used, and retain the 
heat better than anything else ; but they are very liable to slip out of place, 
and are unsuited for infants on account of their weight. In the early stages 
aconite is of sen-ice, one or two drops of the tincture being given every 
two or four hours, being watched carefully lest it produce too much depres- 
sion. In many cases no other treatment is required, the aconite being- 
stopped when the crisis comes.' If the temperature is not excessive, not 
much exceeding 103 , no special methods of reducing it need be used, as the 
course of the fever is short, and often after the first day or two it takes a 
lower range : the initial fever in the case of infants and young children is in 
some cases high, and is, apparently, the cause of the cerebral symptoms, such 
as convulsions and coma, from which they suffer, and which sometimes prove 
fatal. When this is the case, no time should be lost in reducing temperature 
by cold sponging, packs, baths, an ice bag to the chest over the seat of the 
pneumonia, or by the administration of antipyretics. If the temperature is 
high — 104 or 105° — there is no need to fear any harm accruing from cold 
water, the simplest method of applying it being by sponging the patient over 
with cold water, or — what is more effectual — by a pack at 6o° or 70 : this latter 
can be applied by wringing a towel out of cold water, folding and applying it 
round the chest, or enveloping the whole body in a wetted sheet. The pro- 
cess may be repeated at intervals of an hour more or less. If these means 
prove inefficient, or if, as in the case of convulsions, there is no time to lose,, 
the cold or graduated bath should be resorted to, the child being placed in a 
warm or lukewarm bath, and the temperature of the water gradually lowered 
to 6o° F. by addition of cold water or ice ; if the patient becomes blue and 
cold he should be removed at once. 

The best antipyretics are quinine and antifebrin and phenacetin, either 
being given in two or three grain doses to a child of three years every four 
hours ; antifebrin is apt to produce considerable depression, which, however, 
quickly passes away ; large doses of quinine are apt to produce dyspepsia. 
The effects of aconite on the pulse should be carefully watched ; any signs 
of intermission or irregularity should be the signal for omitting it, for a while 
at least, and submitting some simple saline, as liq. amnion, acet. or citratis ; 
alcohol and stimulant expectorants are best avoided in the early stages ; two 
or three drop doses of tr. digitalis, given every four hours, are often useful 



Croupous Pneumonia 233 

if the pulse is poor ; citrate of caffeine or sulphuric ether may also be 
given. 

In cases where the crisis is delayed on account of the inflammatory process 
extending, as in the creeping form, and when the child seems low and weak, 
there is always a temptation to give ammonia and stimulants, and these may 
in some cases be needed, especially in hospital patients who are seen for 
the first time after some days' illness ; but our impression is that patients do 
better in the inflammatory stages, when the process is still extending, on 
small doses of aconite, antimony, or salines, than they do on a too stimu- 
lating treatment. An occasional dose of alcohol may do good when a con- 
tinuous dosing is harmful ; alcohol in large doses acts as a narcotic, and is- 
apt to add to the drowsiness and tendency to delirium. Opium in the form 
of ' nepenthe ; or Dover's powder is of great value in calming the delirium 
and sleeplessness, as well as soothing the irritable cough and relieving pain 
when this is a marked feature, as it is in the pleuritic complications. One 
to three drops of nepenthe or half to two grains of Dover's powder may be 
given at night to procure rest and sleep. In double pneumonia, where there 
is much depression with a failing pulse, ether and digitalis must be resorted 
to. Ether may be injected in three or five drop doses subcutaneously, or sp_ 
aetheris and tr. digitalis may be given every few houis. Champagne is a good 
restorative under these circumstances, but it may cause vomiting if given too 
freely, and it will be well to dilute it with soda water in the case of young 
children. 

Gangrene of the Xiiing- 

Croupous pneumonia, when it attacks children already the subject of 
chronic bronchitis and emphysema, is apt to terminate in gangrene of the 
lung; this we have seen on several occasions. It is apt to follow pneumonia 
secondary to scarlatinal nephritis and also whooping cough. The principal 
diagnostic symptom is the exceedingly foul breath ; the temperature is 
usually high, sometimes hectic, suggesting pus, and the pulse is rapid. The 
lung is found at the post-mortem in a state of grey hepatisation, breaking- 
down into ragged cavities and smelling offensively. 

Gangrene of Lung; Pyopneumothorax.— Joseph P., aged 9 years. Mother states 

he has been subject to bronchitis in the winter.. On September 10 he came from school 
complaining of a pain in his side and bad cough. He has been spitting some blood. 
On admission, September 27, 1894, he is a thin, delicate-looking boy, with clubbed 
fingers. On examination of the'ehest : the right side has a boxy note, except at the b 
behind which is dull ; the breath sounds are very faint ; some friction sounds in the axilla : 
the left side is normal, except that the breath sounds are exaggerated. There is not much 
dyspnoea, but he is subject to paroxysms of coughing, when he brings up considerable 
quantities of very foetid pus. October 2. — Paroxysms of coughing ami foetid expectora- 
tions ; some dullness at left base behind. Coarse crepitation anteriorly on right - 
Explored right side subcutaneously in several different places, but failed to find pus, 
October 3.— Much collapse. Death October 6. 

Post-mortem. — Right lung adherent in front, in axillary region pyopneumothorax; 
pus very foul; small cavity in middle of lobe, communicating with bronchus am! 
pleural cavity ; patches of consolidation throughout the lung becoming gangrenous ; no 

definite tubercle. Left lung adherent behind; recent pleurisy. Heart and other org 

show nothing abnormal. 



.234 Diseases of the Respiratory Apparatus 



Abscess of the Lung 

Purulent collections in the lungs are mostly the result of septic embolism 
from some distant suppurating centre, as in an otitis or some other bone 
lesion, and are associated with pyaemia. They are usually small and situated 
on the surface. Small abscesses may be secondary to an empyema, the latter 
finding its way idd a small abscess into a bronchial tube. Minute abscesses 
are sometimes a sequence of a broncho-pneumonia secondary to scarlet 
fever, measles, or whooping cough, suppuration taking place in the lobules 
immediately surrounding the terminal bronchioles ; here small centres con- 
taining pus may be found (see p. 219). 

In both gangrene and abscess of the lung, if the lesions are fairly 
localised, or the disease progressing, an attempt should be made to 
arrest the mischief by incising and draining the abscess or gangrenous 
cavity. For this purpose it is necessary to localise the abscess, first by the 
physical signs as far as may be, and, secondly, by exploration with an 
aspirator needle, though, if the evidence is otherwise strong, failure to draw 
off pus by the aspirator should not prevent a further exploration; the incision 
should be made over the abscess, and, if necessary, one or more segments 
of rib removed ; the lung should then be incised and drained, and treated on 
•ordinary surgical principles. We have incised and drained a hydatid of the 
lung and a pulmonary abscess, with considerable relief to the children in each 
instance. 

Pleurisy and Empyema 

That pleurisy must be a common disease in children is shown by the 
frequency with which the lungs are found adherent to the chest walls when 
making autopsies on children who have died from various diseases. Here, 
,as in the case of adults, the evidence of a past pleurisy is conclusive. Yet it 
cannot be said that pleurisy is diagnosed and treated with any great 
frequency "during life, the reason no doubt being that young children are not 
able to localise attacks of pain, that when fretful it is not easy to thoroughly 
examine their chests by auscultation, and, moreover, the symptoms may be 
masked by other diseases in which the pleural lesion plays but a secondary 
part. 

Pleurisy, primary and acute, occurs at all ages during infancy and child- 
hood, the first year of life being by no means exempt. It is apt to follow 
•exposure to cold or, not infrequently, an accident, such as a fall or blow on 
the chest. It is, however, far more commonly associated with a croupous, 
catarrhal, or septic pneumonia. It occurs very frequently in connection with 
tuberculosis of the lung. 

Symptoms. — Pleurisy may begin suddenly and run an acute course, though 
more often it is subacute. The attack begins with a short cough, fever, 
shallow respiratory movements, the affected side moving less than its fellow, 
accompanied by sharp pain, which the child, if old enough to do so, refers to 
the side or very often the epigastrium. In infants the attack maybe ushered 
in by convulsions and its course may be marked by screaming fits, especially 
if the child is disturbed. If the pleurisy is extensive and acute, an examination 



Pleurisy 235 

of the chest shows the respirations to be shallow, and the movements of 
the affected side extremely limited, while percussion or pressure in the 
intercostal spaces with the finger gives rise to expressions of acute pain. 
On auscultation, while the breath sounds are loud and clear on the normal 
side, they are weak on the affected, and perhaps accompanied by a friction 
sound. The pulse is quickened and there is fever, perhaps ioo° to ro2°, unless 
pneumonia is present, when it is probably higher. The further course of the 
attack varies according to whether effusion of serum occurs or not. In the 
latter case, in the course of a few days the fever subsides, the friction sounds 
disappear, though perhaps some 'stitch' (stabbing pain in the side) remains 
for a while. In many cases apparently a local pleurisy takes place during the 
course of a bronchitis or bronchial catarrh in which little else than a sharp 
pain in the side or abdomen is present. 

In pleurisy occurring between the diaphragm and lung the symptoms are 
generally obscure, there is pain and tenderness in the epigastric or hepatic 
region, with thoracic breathing, the abdominal muscles and diaphragm being 
kept as quiet as possible. Should effusion take place in any quantity, 
signs of its presence quickly appear. The child will probably lie on the 
affected side, so as to give full play to the lung on the sound side ; the infant, 
as Henoch points out, with fluid in the right pleural cavity takes only the left 
breast of its mother for a similar reason. On inspection it will be noted that 
the side containing the effused fluid moves less freely than the other, and if 
the fluid is in the left chest, the cardiac impulse is displaced towards the 
right side. In large pleural effusions on the right side, the impulse may 
be moved towards the left. This displacement of the cardiac impulse is 
of special value in the diagnosis of fluid in the chest in children, on account 
of the uncertainty and small value of some of the other physical signs ; 
as, for instance, the vocal resonance and fremitus, which yield valuable in- 
formation in adults. The position of the heart's impulse is best ascertained 
by placing the surface of the hand on the chest wall, and, if necessary, by 
determining by auscultation the position of the heart by the comparative 
loudness of its sounds. It is necessary, however, to remember that the heart 
may be displaced without any fluid being present at the time of examination, 
as it may have been pushed on one side by a former effusion and have become 
fixed in an abnormal position by fibrous adhesions ; in this case the lung also 
will probably be adherent, and a dull note may be elicited over it which 
suggests the presence of fluid. The heart may also be pulled on one side or 
upwards by a fibroid condition of lung or chronic pleurisy. 

On percussion of the chest, a dull or much impaired resonance will be 
■detected over the area occupied by fluid, while in most rases the sub- 
clavicular region and frequently also the supra-spinous fossa and possibly a 
strip between the base of the scapula and the spine will be resonant, often 
hyper-resonant. If the effusion is great the whole side will be completely 
dull and give a sense of resistance on percussion. Chi auscultation the 
breath sounds are weak and distant, but usually ot a distinctly bronchial or 
tubular character. In the earlier stages of effusion the expiratory murmur 
is especially accentuated and bronchial, the air from the compressed lung 
being, as it were, expelled with difficulty. The breath sounds en the healthy 
side arc exaggerated. The vocal resonance ami fremitus may be absent or 



236 Diseases of the Respiratory Apparatus 

weak, but it may be impossible to elicit any information in this way, as the 
voices of children, especially girls, are weak, and moreover they may not be 
old enough to understand what they are wanted to do. During crying, in- 
formation of value may sometimes be obtained by placing the hand on the 
chest. Comparative measurements of the two sides show the affected 
side in recent cases to be larger than the other ; but too much value must 
not be attached to measurements, as in chronic cases some amount of re- 
traction may have taken place. Of more value is the cyrtometer tracing ; this, 
as pointed out by Dr. S. Gee, shows a change of shape from the elliptical to 
the more circular form without the circumference necessarily being increased. 

Should a large amount of fluid be poured out in a short space of time, it 
will necessarily give rise to dyspnoea : the child will turn over on to the 
affected side or lie upon its back ; the alae nasi work, and the number of re- 
spirations is increased perhaps to forty or fifty. If the amount of fluid is 
smaller in quantity, the child may be tolerably comfortable while lying at 
rest, but there is dyspnoea on the slightest exertion. The amount of feverish- 
ness varies ; during the inflammatory stage before or during the period the 
serum is being poured out the temperature is usually raised two or three 
degrees ; in the course of a few days a gradual fall takes place, and there may 
be no fever or only a slight elevation at night. 

Under favourable circumstances in a healthy child, the serum effused 
begins to be reabsorbed : this it usually does in the course of a few days, 
the heart if displaced returning by degrees to its normal position, the level of 
the fluid becoming lower and lower, till the side regains its normal resonance ; 
or, what is much more likely, a somewhat impaired resonance, which it retains 
for many weeks. The reason of this is doubtless that the re-expanded lung- 
remains for some time in a sodden and congested state, and not improbably 
its pleural surface contracts adhesions with the chest wall. During the 
stage of reabsorption friction and moist rales are frequently heard in the 
lung, and the breath sounds are weak. In some cases, however, this desirable 
reabsorption does not at once take place. The child ; s health is impaired, 
he is anaemic and depressed, perhaps thick layers of lymph are covering the 
pleural surface of the lung and chest wall, and conditions are not favourable 
for the reabsorption of the fluid after the inflammation has subsided ; or 
possibly the absorption may go on extremely slowly, pari passu with the 
organising of the lymph which has been poured out. Under these circum- 
stances much damage may be done, the heart may be fixed in a malposition,, 
the lung may become tied down by a thick layer of fibroid tissue which 
contracting holds the lung in its grip, while the chest falls in and the spine 
becomes curved. 

But besides a quick reabsorption of the serum, and a chronic pleurisy 
with its slow course, another result may follow, and that is — at least this 
is what is usually believed— the serum may become pus ; this, however, is not 
a common result if the fluid effused is at first serum, and it rarely happens 
that it remains so for some weeks and then finally becomes converted into 
pus. An empyema, as a rule, is an empyema from the first, at least the fluid 
effused is turbid-looking at first ; in other words, it is thin pus, and later it 
becomes thick pus. It is no doubt most common to find that where there is. 
reason to believe fluid has existed in the chest for some weeks or months,. 



Empyema 



237 



the fluid is pus and not serum, but then in all probability the fluid lias been 
pus from the first and has failed to be absorbed, whereas had it been serum 
it would have been. Serum may undoubtedly remain in the chest unaltered 
for many weeks, perhaps months ; but this is uncommon except in cases of 
tubercle, or new growths in the lung, or in cardiac disease. An empyema is, 
in the vast majority of instances at any rate, the result rather of a pleuro- 
pneumonia than a simple pleurisy. The more intense the inflammation 
the more likely it is that pus, not simple serum, is poured out, or that 
the serum poured out quickly becomes pus. This is especially likely to 
happen if a pleuro-pneumonia follows scarlet fever, measles, or whooping 
cough, or indeed any pneumonia of the croupous type. The symptoms given 
by an empyema are by no means distinctive as between pus and serum, and 
often no definite diagnosis can be arrived at until an exploratory puncture 




Fig. 33. — Temperature Chart of a case of Pleuro-pneumonia followed by Empyema, in a girl of 
nine years. Signs of fluid were discovered on the sixth day, pus on the eleventh day ; on the 
seventeenth day the chest was incised, followed by a fall in the temperature. 

has been made. In favour of pus in acute cases would be the occurrence of 
pleurisy as a sequel of a zymotic disease, especially in a weakly child : in 
chronic cases the presence of hectic, diarrhoea, a sallow earthy complexion, 
the 'pointing' of a collection of fluid in connection with the chest. A collec- 
tion of purulent fluid may be present in the chest and give very few signs of 
its presence, except the physical signs. It must be remembered that in any 
chronic case of fluid in the chest in a child, that fluid is probably pus, but not 
universally so. The early history of an empyema is generally that oi an 
acute pneumonia which docs not clear up, and the presence o( pus in the 
chest is likely to be thought to be consolidation o\ the lung, especially as 
there may be well-marked bronchial breathing. As an illustration of this 
the following case may be cited. 

A girl of nine years \\ .is convalescenl from scarlet fever. On the 1 lay the 

temperature rose- to 105 , there \\.i^ intense pain referred to the leu - 



238 Diseases of t/ie Respiratory Apparatus 

epigastrium, especially felt when she turned in bed, there was also some want of resonance 
at the left apex. On the third day of the attack there was diminished resonance over the 
whole left side, with bronchial breathing ; no displacement of the heart. On the sixth day 
there was slight displacement of the heart to the right, the dullness over the left chest was 
much more marked, the breath sounds were faint and bronchial. On the eleventh day 
the signs of fluid had increased, the heart's impulse being felt at the left border of the 
sternum ; an exploratory puncture showed the presence of pus. On the seventeenth day 
the chest was incised antiseptically, pus and much lymph escaped, a tube was inserted,, 
and complete recovery ensued (see fig. 33). 

It must always be borne in mind if a croupous pneumonia does not clear 
up and the dullness disappear, or if the temperature remits instead of 
falling when the time for a crisis comes, pus may be present in the chest. 
In such cases the signs of consolidation of lung are gradually replaced by 
those of fluid, the latter accumulating as the pneumonic consolidation dis- 
appears. 

Pus may be present in the chest, yet not free in the pleural cavity, but 
confined by adhesion between the lung and chest wall or diaphragm. More 
than one localised empyema may be present on the same or opposite sides 
Such localised collections may be present in any part, as at the apex in front, 
the base behind, or in front between the pericardium and anterior edge of 
the left lung, or between the lung and the diaphragm. These small empyemas 
are often associated with broncho-pneumonias and chronic tuberculosis of 
the lung. It is perfectly obvious that if these "collections of fluid are not 
large and are surrounded by and backed up by crepitant lung, diagnosis 
will be by no means easy, and it is not surprising that such should be found 
on the post-mortem table, having escaped discovery during life. In these 
cases the physical signs are not distinctive ; there will mostly be a patch 
of dullness, with more or less resistance, but an adherent lung with thick 
fibroid tissue between it and the chest wall will give a similar note. The 
breath sounds are weak, perhaps bronchial. When in doubt it is wise to 
explore, not using too fine a needle, as if the bore is too small it is apt to 
become blocked with a flake of lymph or pus. If the layer ofpus is not thick 
the needle may pass through the pus into lung beyond. 

Diagnosis. — The distinction between the consolidation of pneumonia and 
pleuritic effusion in typical cases is made readily enough. The intense 
bronchial breathing, with the clear, ringing rales and impaired resonance of 
pneumonic consolidation, form a marked contrast to the weak, distant breath 
sounds, wooden dullness, and displaced heart distinctive of a large effusion 
of fluid. In many cases, however, no diagnosis is possible without an ex- 
ploratory puncture, and even then a negative result does not definitely settle 
the matter, as it is quite possible to miss the fluid. A pneumonic lung 
covered with a thick layer of lymph, or a sodden lung covered with fibroid 
tissue and adherent to the chest wall, gives a wooden dullness and resistance 
closely resembling that of fluid. On the other hand, when fluid is present 
the bronchial breathing is sometimes loud and even intense. A good rule 
to follow is, whenever there is a patch of dullness that does not clear up, 
especially where there is a hectic or elevated temperature, always to explore 
by means of a subcutaneous syringe. The diagnosis between a local or 
small collection of fluid at a base and chronic pneumonia, caseous pneumonia 



Empyema 239* 

and tubercular consolidation, is often far from easy, and indeed is generally- 
impossible without exploration. There may be dullness and a hectic tem- 
perature, moreover there may be a patch of impaired resonance in the axilla 
while the apex and base are resonant, or both sides may be affected. 

In one of our cases there was intense bronchial breathing and increased 
vocal resonance over the whole of the right lung, except at the base ; it was 
very dull all over. We removed 7 oz. of pus and more drained away after- 
wards. 

Morbid Anatomy. — It is not often that an opportunity occurs of examin- 
ing the chest of a child that has died of uncomplicated pleurisy or empyema, 
though it is common enough to find both in association with pneumonia or 
tuberculosis. The pleurisy differs much in degree, from a simply roughened 
surface to a layer of thick lymph ; the adhesions which result from the 
organising of the lymph also varying greatly in toughness and thickness. 
Serum in varying amount, perhaps in greater quantity than was suspected 
during life, may be found in association with pneumonia, especially in such 
diseases as nephritis, septicaemia, and scarlet fever. The lung corresponding 
to the position of the fluid is collapsed and airless. The result of a past 
pleurisy, especially when this has been chronic, is sometimes seen at thepost- 
mortcm in the shape of thick fibroid adhesions which completely surround. 
and infiltrate the lung. The latter is completely adherent, airless, in a 
condition of cirrhosis, traversed by bands of fibroid tissue, and occupying a 
position at the posterior aspect of the chest in contact with the spine. In 
other cases there may be found adhesions connecting both lungs with the 
chest wall and diaphragm, and on cutting through the lungs they appear to- 
be riddled with cavities, which are in reality dilated bronchial tubes. The 
relation between empyemas and tuberculosis is interesting and important. It 
is believed by some that the subjects of chronic empyemas are apt to become 
tubercular ; in other words, patients who suffer from a chronic empyema are 
likely to die of phthisis. We do not think, at least as far as our experience 
goes, that there is any post-mortem evidence to support this. That chronic 
pneumonia may terminate in tuberculosis by the mediastinal glands becoming 
caseous is an almost every-day experience, but this certainly does not apply 
to empyema. Barlow and Parker, however, state that they have met with 



cases where they believed atubcrculosis was secondary to a chronic empyema. 1 
Localised collections of pus may sometimes be found in connection with 
chronic tuberculosis, but in these cases the pus is apparently secondary to the 
tubercular process. 

Suppurative or simple pericarditis may take place by extension of the 
inflammation from the pleura. 

Treatment. — In the early stages of dry pleurisy where the pain is severe 
the child is necessarily placed in bed, small doses of an anodyne being given 
and hot applications applied to the chest. Small doses of opiates relieve the 
pain best, such as Dover's powder or ._,'„ ,'., grain of morphia given sub- 
cutaneously ; the latter may be administered to children over four years, but 
not to infants. Hot poultices may be used with less fear than in pneumonia 
where much lung is involved. Strapping the chest on the affected side with 
strips of belladonna plaster is often very useful. 

1 Dr. Uutton has also seen such cases. 



240 Diseases of the Respirator)' Apparatus 

The natural course of a dry pleurisy is towards recovery, the inflamma- 
tory condition of the pleura subsiding, the lymph effused being organised, 
and the lung becoming adherent to the chest wall. The adhesions thus 
formed differ very much in their firmness and strength, the lung being 
perhaps only loosely attached to the parietes, so that its movements are only 
slightly if at all impaired, or firmly attached by thick leathery adhesions, 
so that it cannot be torn away without damage. In the latter case the ad- 
hesions are extensive, the movements of the lung are impaired, it never 
properly empties itself of air, and it is in consequence always more or less 
in a congested or cedematous condition, and possibly becomes infiltrated with 
fibroid tissue while the bronchial tubes become dilated. Such cases are 
probably the result of chronic or subacute pleurisy ; the chest may also con- 
tract and fall in. When an effusion of fluid has occurred, in the vast 
majority of cases reabsorption takes place after the inflammatory condition 
of the pleura has subsided, and the tension of blood in the vessels has become 
reduced to normal. Life, however, may be threatened from the excess of fluid 
thrown out ; under these circumstances nearly the whole of the blood in the 
body is passing through the sound lung ; it is consequently intensely con- 
gested, and may become cedematous. Moreover, the right side of the heart 
is over-distended, and as a consequence sudden death is apt to ensue. For 
this reason no time should be lost, if the dyspnoea and distress become great, 
in relieving the chest by the withdrawal of some of the effused fluid. On the 
other hand, the mere presence of fluid in the chest, if there are no signs of 
distress, does not necessitate operative interference, as in the great majority 
of cases absorption takes place in the course of a few days or a week. Opera- 
tive interference, therefore, is called for in all cases where there is dyspnoea 
or orthopncea when lying quietly in bed, or where there is much displacement 
of the heart. In those chronic cases where the fluid is not absorbed or is not 
diminishing in quantity after the lapse of a few weeks, the serum may be 
removed from the chest by means either of the aspirator or by trocar and 
canula, the small ones introduced by Dr. Southey for the removal of the 
fluid in ascites answering very well. Whatever method is selected, the fluid 
should be removed slowly, and there is no necessity to remove all that can 
be aspirated. Too rapid aspiration of the fluid is apt to lead to bleeding 
into the chest from rupture of some of the capillary vessels, and may possibly 
cause emphysema of the lung on account of one part of the lung expanding 
faster than the other. On the whole, we believe the best results are obtained 
by the use of Southey's trocar and canula. One of these may be introduced 
without difficulty and without pain if local anaesthesia be produced, a piece of 
fine india-rubber tube attached, and the fluid allowed slowly to drain away 
for a couple of hours or so, 10 to 20 ozs. being thus withdrawn ; if neces- 
sary two canulae can be inserted. In those cases where the dyspnoea 
is extreme, relief is more quickly obtained by aspiration. It may not im- 
probably happen that the pleural cavity in part fills up again and a second 
or a. third removal be required. In the less acute cases, where there is no 
urgency and no removal is attempted, the child should be confined to bed in 
a warm room and carefully protected from cold. It may be doubted if any 
drug materially aids the reabsorption of the effused fluid, though the usual 
treatment in such cases — namely, giving iodide of potassium internally and 



Treatment of Pleurisy and Empyema 241 

painting liniment of iodine mixed with an equal quantity of glycerine exter- 
nally — appears to be useful. The lin. iodi by itself requires using with care, 
especially in young or weakly children. 

The natural course of an empyema differs from that of a simple serous 
effusion. In a minority of cases, especially where the empyema is small 
and confined by adhesions, it may dry up, and the inspissated pus in time 
become cretaceous. But this event can hardly be expected, and should it 
take place, especially if the empyema be a large one, the result, accompanied 
as it is by retraction of the chest and compression of the lung, is anything 
but satisfactory. The presence of pus in the chest is inconsistent with good 
health, to say nothing of the risks the patients run of its burrowing in various 
directions. The child with a chronic undrained empyema probably suffers 
from hectic fever, is anaemic and sallow, the skin becomes rough, the fingers 
clubbed, and the child emaciates. Various other results may follow ; the 
pus may find its way through the intercostals, and point in the fourth or 
fifth space, it may then gradually undermine the skin and a chronic 
discharge take place. It may open through the lung into a bronchial tube 
and be gradually coughed up ; in this way recovery may eventually take 
place, though the process is a slow one ; or an abscess or abscesses may 
form in the lung. An empyema on the right side may, either by con- 
tiguity or by opening through the diaphragm, give rise to an abscess in the 
liver. It may open into the abdomen by finding its way through the diaphragm, 
and set up peritonitis. The pus may burrow any distance, opening through 
the abdominal walls or simulating a lumbar abscess. 

Directly a diagnosis of pus in the chest is made, arrangements should be 
made to evacuate it, and this in the vast majority of cases should be by free 
incision and drainage. Aspiration may be tried once or twice in local 
empyemata, especially in infants and small children, but it is only in the 
minority of cases that it will succeed, as the cavity usually fills up again 
and separates the parts which should be kept in contact if a cure is to result. 

The surgical treatment of suppuration within the pleural cavity is based 
on the ordinary principles guiding us in the management of abscesses else- 
where. Hence, although it occasionally happens that pleural abscesses dry 
up and do not discharge at all, or discharge through the lung or elsewhere 
and then heal, none of these possibilities should be looked for, and the treat- 
ment practically resolves itself into tapping and free incision. 

Tapping an empyema with a simple trocar and allowing the fluid to drain 
away through a tube into an antiseptic lotion is a mode of treatment that 
is successful in certain cases, but is open to several objections. The cases 
for which it is suitable are those where the empyema is recent, of small size, 
contains no masses of lymph or caseous material, and where the lung is not 
bound clown by firm adhesions but is ready to expand on removal of the com- 
pressing fluid; further, it is important for the successful employment of this 
plan that the pus be contained in one cavity only and not be loculated. The 
dangers of tapping are the risk oi wounding the lung by thrusting the trocar 
too far inwards on the one hand, and on the other the possibility of pushing 
the thickened pleura or a layer o\ Lymph before the trocar so that the 
abscess cavity is not opened. There is also the likelihood o( the canula 
becoming blocked with Lymph or caseous material, and of incomplete 

K 



242 Diseases of the Respiratory Apparatus 

emptying of the cavity because it is loculated or because the lung cannot 
re-expand. 

Aspiration is open to the same objections, with the additional one that if 
too powerful suction is employed there is likely to be bleeding from the 
surface of the lung or the pleura, and the cavity may become partially filled 
with clot which readily decomposes. 

The difficulty of emptying the cavity when the lung cannot re-expand has 
been met by Mr. R. W. Parker by the plan of injecting aseptic air into the 
pleura to replace the pus as it flows away, or lotions may be used with the 
same object ; but the plan has not met, and is not likely to meet, with general 
approval. Aspiration, then, should be employed for small, single, recent em- 
pyemata, and in some few of such cases after one or two tappings the pus will 
cease to be secreted. Should there be chronic disease of the lung, caseous 
material, glandular or other, or disease of the ribs or spine, since the source of 
irritation remains, pus formation will go on and aspiration cannot be sufficient. 
Failing, then, tapping or aspiration, the remaining resource is free incision 
and drainage of the abscess. The general plan of operation may be described 
first, and certain special points alluded to afterwards. 

The incision should be an inch or more in length, and should be made 
along the lower margin of the space selected, so as to avoid injury to the 
intercostal vessels. The tissues should be gradually cut through until the 
pleura is reached, all bleeding being arrested before the pleura is opened. 
If the membrane is not much thickened, a sharp director may be thrust 
through it and used as a guide for the knife : if, however, it is very tough 
and thick, as may be the case if the disease is of long standing, it is better to 
incise it at once with the knife. As soon as the cavity is reached a pair of 
dressing or sinus forceps should be passed in. opened, and the pus allowed 
to escape freely. The drainage tube is then to be inserted and secured by a 
thread round the chest unless a special tube is employed. Possibly the 
dressings will be soaked and require changing in a few hours ; if, however, 
the cavity is fairly emptied and thick wood-wool pads are employed, this is 
not likely to be the case. 

The spscial points to be considered are the position of the incision, the 
drainage tube, the management of adhesions, and the washing out of the chest. 

First, then, the position of the incision. Where the empyema is local the 
incision must of course be made over it, and the lowest convenient spot for 
drainage should be chosen. Where the whole pleural cavity is filled with 
pus a difference of opinion exists as to the most suitable spot for the opening. 
Mr. Marshall advocated an incision in the front of the chest, others prefer 
the axilla. We think, however, on the whole, the best place is just behind 
and below the angle of the scapula in the eighth interspace ; this spot 
affords good drainage when the patient lies on his back or side, it is not 
quite so convenient for dressing, but it is nearly at the lowest point of the 
cavity, yet not so low as to risk injury to the diaphragm, which is liable to be 
drawn up to take the place of the shrunken lung. 1 Unless the incision is 
made too far back there is no great thickness of muscle to cut through. 

1 The objection that an empyema usually heals up at the back first, and that therefore 
a cavity is likely to remain unclosed in front, has not in our experience proved a valid 
objection to the posterior incision. 



Empyema 243 

As to drainage, though in some cases where the chest is very full of 
fluid the intercostal spaces may be widened and bulging, yet much more often 
this is not so, and the ribs are so close together that it is difficult to get 
a tube into the chest, and when inserted it is liable to be nipped by pressure 
of the ribs. In such cases the ribs should be prised apart with dressing 
forceps, and a rigid tube, such as a silver or vulcanite tracheotomy tube, 
employed, or a piece of rib should be excised, which is a far better plan. 
The tube should not project far into the pleural cavity, but only just enough 
to be clear of the thickened pleura, otherwise it will fail to drain the cavity, 
and may be blocked by pressure against the lung. A double tube, or two 
pieces of tubing fixed together side by side (Battams), are preferred by some 
surgeons ; the plan is useful if it is intended to wash out the chest, but in many 
■cases it is open to the objection given above. 

After opening the chest a finger should be passed in if possible to 
ascertain the size of the cavity and to break down any adhesions shutting in 
localised collections of pus, 1 as well as to remove any masses of lymph or 
solid material in the cavity. If the pus is foul or thick and flaky, as large a 
tube as possible should be put in, and all solid and offensive matter care- 
fully removed after resection of a portion of a rib. Should any bleeding 
occur from the intercostal vessels, they may be picked up or secured by 
a catgut ligature, passed round the rib including the vessel ; this is easily done 
with an aneurism needle. Bleeding from the granulating surface of the pleura 
after exploration soon ceases of itself, but all clots should be washed out. 

During the operation careful watch must be kept by the anaesthetist that 
the child does not suffer from having to lie upon the sound side, and at any 
sign of failing pulse or respiration the child must be turned upon its back or 
towards the affected side. The after-treatment of empyema consists in 
keeping the cavity aseptic and well drained ; obstruction of the tube is most 
likely to be due to flakes of lymph or to slipping of the tube if a rigid one is 
used, to nipping of the tube by the ribs if rubber is employed. As regards 
washing out the chest it must be remembered that there is a certain amount 
of danger in it ; cases of sudden death during the process have several times 
been recorded, possibly from irritation of cardiac nerves in the wall of the 
cavity, or from sudden dyspnoea ; this risk should deter us from washing- 
out an empyema unless the discharge continues to be foul, and it should 
lead to caution and the avoidance of any distension of the cavity or the use 
of irritant lotions even in such cases. In free incision of the chest the opening- 
is of course large enough to admit air readily, hence there is no obstacle to 
complete emptying of the cavity. The tube should not be left out until the 
discharge has nearly or quite ceased, and exploration with a probe has shown 
that the cavity is filled up ; often, though there is but little discharge, a good- 
sized cavity or a long sinus remains, and if the external wound is allowed to 
close, fresh collections of pus will take place. In a certain number of cases 
the empyema will be pointing externally when the case is first seen ; such 
pointing most commonly occurs in the front of the chest from the second to the 
fifth space, the matter sometimes pushing forward and pointing through the 
mamma. If the skin is already thinned the pus should be let out at this spot 
and the case managed as usual ; if, however, the cavity docs not drain freely, a 
1 Or. Fagge states that loculation is very rarely found post m 

K Z 



244 



Diseases of the Respiratory Apparatus 



long probe should be passed through the anterior orifice, and cut clown upon at 
a more dependent spot, and a drainage tube inserted there. While admitting 
that the successful management of empyema is not simply a question of 
drainage as in other abscesses, we think a dependent opening is a highly 
important matter. A free outlet is absolutely essential. 

Sometimes the pressure of the drainage tube causes ulceration of one of 
the ribs ; this is, however, a matter of little importance, since the rib usually 
recovers after removal of the tube. 

In a certain proportion of cases after drainage of the empyema the cavity 
does not become obliterated, but remains as a pus-secreting sac ; this is due 

either to imperfect expansion of 
the lung or insufficient compen- 
satory falling in of the chest wall. 
Under such conditions the dis- 
charge may go on indefinitely and 
cause lardaceous disease and 
hectic fever ; it is then necessary 
to find other means of allowing^ 
the surfaces of the abscess sac to 
come together. For this purpose 
resection of one or more ribs 
(Estlander's operation *) has been 
devised. Although in children,, 
from the softness and flexibility 
of the ribs and spine, the chest 
generally falls in readily, this is 
by no means always the case, and 
the operation should be done as 
soon as it is clear that progress 
is not being made or the child's 
health is failing. Where there is 
an insufficient opening for drain- 
age, it is also necessary in some 
cases to provide a larger orifice 
by removal of part of a rib ; and, 
indeed, it is a good practice to 
excise a portion of rib in all cases 
where the child is not so feeble as 
to make even this slight addition to the severity of the operation undesirable. 
The operation is a simple one ; to remove a single rib, the lowest one in the 
cavity should be chosen, usually the seventh or eighth. An incision is made 
along it down to the bone, the periosteum is readily peeled back with a 
raspatory, and about an inch or more of the rib is cut out with bone forceps ; 
the periosteum and pleura are then incised parallel with and avoiding the 
intercostal vessels ; if the artery is wounded, however, it is easily secured 
now that the rib is gone. When the resection is done to allow collapse of 
the chest wall, from two to five ribs may have to be resected, two or three 

1 Estlander's operation is strictly the removal of a sufficient part of the chest wall to- 
allow of complete collapse. 




Fig. 34. — Deformity of Chest due to Empyema. 



Empyema 245 

inches of bone being taken from each ; in such case a quadrilateral flap of 
the soft parts should be turned forward and the ribs removed one after the 
other. Though it is perhaps better in such cases to remove the bones 
subperiosteally, the periosteum should be cut away before closing the wound, 
otherwise it often happens that ossification rapidly takes place and fills up 
the gap in the chest wall and so prevents the desired collapse. We have 
sometimes found the intercostal vessels obliterated in these cases, and there 
has been no arterial bleeding at all. Marshall has divided the costal 
■cartilages subcutaneously with the same object, but resection is the more 
■complete operation, and it sounds and looks more formidable than it is. 
The subsequent management of the wound requires no description. Unless 
an empyema speedily recovers, more or less retraction of the side necessarily 
results, and from this a lateral or rather, as Lane has pointed out, a true 
rotato-lateral curvature of the spine follows : this of course is largely 
irremediable, but some improvement may be obtained by treatment {vide 
Lateral Curvature). (Fig. 34.) 

Inasmuch as the ribs are less yielding near the angles, it is better to 
remove the bone as far back as possible up to the edge of the erector spinae. 
We have tried osteotomy of the rib at the posterior part at the same time as 
resection to allow more complete falling in of the chest wall, but found little 
was to be gained by this means, since the rib is held firmly in place by the 
surrounding soft parts. 

Asthma 

Spasmodic asthma is by no means uncommon among children. Bronchial 
spasm is sometimes secondary to dentition ; a child when cutting a tooth 
begins to wheeze, especially towards evening, and on placing the ear to the 
chest sibilus may be heard. A condition of asthma or urgent dyspnoea is 
frequently present in the uraemia of scarlatinal nephritis and in the rare 
cases of contracted kidney which occur in children ; it may be open to 
doubt if in such cases the origin is not cardiac, rather than due to any bron- 
chial spasm. Hysterical children sometimes have attacks resembling asthma. 
The commonest form, however, is bronchial or spasmodic asthma, resembling 
the asthma of adults ; these children are exceedingly liable to bronchial 
catarrh. In most of these cases this disease is hereditary, and may begin 
as early as two years of age. The attack begins with the symptoms of a 
cold in the head or a bronchial catarrh lasting for a few hours or days, then 
an attack of dyspnoea occurs, perhaps at night-time ; the child sits up in bed 
and fights for his breath, the breathing is quick, the alae nasi work, the lips 
are blue ; the attack lasts from a few minutes to an hour or two, and is 
followed by freer secretion and relief. Some attacks are associated not 
with bronchial catarrh but with dyspepsia, and have been termed asthma 
dyspepticum by Henoch, the child having an asthmatic attack when suffering 
from dyspepsia or after taking improper food. Instances have occurred in 
which enlarged tonsils and post-nasal adenoids have appeared to have had 
a hand in producing such attacks. The treatment must be directed to 
prevent children from taking cold or becoming dyspeptic. Some high, 
bracing, dry, inland site usually suits such children better than the seaside. 
The east winds of spring are especially liable to excite an attack. A house 



246 Diseases of lite Respiratory Apparatus 

uniformly warmed throughout, so that the child, who is necessarily confined 
much to the house, can wander from one room to another without the risk 
of cold, is a great advantage. An attack may usually be relieved by the 
burning of nitrate of potash papers, and by lobelia. Arsenic is the best 
remedy, with cod liver oil between the attacks. Iodide of potassium is also 
very useful. The bowels require attention ; Carlsbad salts or some other 
saline aperient being useful for this purpose. Enlarged tonsils and post- 
nasal adenoids should be removed. 



Diseases of the Bronchial Glands 

The tracheo-bronchial glands are situated in the middle mediastinum in 
close relationship with the trachea and bronchi ; they are some ten to 
twelve in number, and are arranged in three groups ; one set surrounds the 
trachea, another group is situated at the bifurcation, and a third around the 
right and left bronchi. The pulmonary glands are situated at the root of 
the lung and accompany the bronchi into the substance of the lung. These 
glands receive the lymphatics of the lungs and bronchi, and like other 
lymphatic glands readily become inflamed and swollen during attacks of 
bronchitis and broncho-pneumonia, especially after measles and whooping 
cough, and are apt to remain chronically enlarged and further to become 
caseous and to suppurate. During this inflammatory process more or 
less thickening and matting often takes place in surrounding parts, so that 
the glands may become adherent to the trachea or bronchi or oesophagus. 
The glands and connective tissue in the anterior and posterior mediastinum 
may also become affected, so that the antero-internal edges of the lungs 
and the whole contents of the mediastinum may become thickened and 
matted together. 

Caseation of the mediastinal glands is exceedingly common in children,, 
and they may be found in this condition in the bodies of children dying of 
various diseases, but they are almost universally caseous in those dying of 
pulmonary tuberculosis or chronic catarrhal pneumonia. In many cases 
of acute or chronic tuberculosis it is clear that the disease in the glands is 
older than the tubercle in the lungs, and has spread from the former to the 
latter. In such cases the glands have become enlarged secondarily to some 
bronchitis or pneumonia, have undergone caseation, and the lungs have been 
infected in consequence of caseating bronchial or pulmonary glands, the 
tubercular disease spreading into the lungs from the root. 

Symptoms. — In the large majority of cases there are no distinctive 
symptoms of caseating mediastinal glands, and per se they are not more 
likely to give rise to symptoms than caseating glands in the neck ; but, inas- 
much as they are so frequently associated with early or chronic tuberculosis 
of the lungs, the subjects of them are hardly likely to present the appearances 
of health. Occasionally, however, they are found unexpectedly in the bodies 
of children dying of other diseases. With regard to physical signs, it must 
be clear from a consideration of the anatomy of the mediastinum that the 
glands lie too deeply to be detected by percussion unless they are enormously 
enlarged ; this may take place in sarcomatous enlargement, but rarely in tuber- 
culosis. It has been asserted that when enlarged they can be detected by a 



Diseases of the Bronchial Glands 



247 



diminished resonance in the interscapular region, corresponding to the first 
three dorsal vertebrae ; but, inasmuch as the thick posterior edges of the lungs, 
besides the aorta, oesophagus, and a mass of muscle, intervene between the 
glands and the surface, it is certain that the enlargement must be very con- 
siderable to modify the percussion note in this position. Enlarged glands are 
more likely to modify the resonance behind the upper part of the sternum 
and adjacent cartilages, but in infants and young children the anterior medi- 
astinum is occupied by the thymus, which would mask any enlargement of the 
lymphatic glands ; and in older children, where the thymus is small, lymphatic 




Kig. 35. — Section through a large mass of cheesy glands at the bifurcation of the trachea, and 
extending along the bronchi into the lung. Two of the glands are beginning to show sign> 
of softening at their centres. (After W. P. Northrup, M.D.) 

glands must be very much enlarged to come to the surface and give rise to 
any dullness, covered as they are by the anterior edges of the lungs. Error 
may easily arise from a dullness due to a past pleurisy and consequent adhe- 
sion along the anterior edges of the lungs. If the results of percussion are 
uncertain, those derived from auscultation arc necessarily more so, except in 
considerable enlargement of glands. Ol the pressure signs, the most reliable 
is weak breathing in one of the lungs in consequence of pressure on the right 
or left bronchus ; this sign is of undoubted value, but as there is usually some 
tubercular lesion in the lungs, this symptom may readily be masked. Attacks 
of paroxysmal dyspnoea, and cough with stridulous breathing, may also be 



248 Diseases of the Respiratory Apparatus 

present on account of the nerves being involved. Swelling of the face and 
distension of the jugulars have also been described, but these are far more 
frequently due to constant coughing than to any pressure on the large veins 
in the chest. A caseous gland not infrequently becomes adherent to the 
trachea or one of the bronchi, and ulcerates into it, and caseous matter may 
be coughed up ; in a few instances it has happened that this takes place 
suddenly and death results from plugging of the windpipe. In other 
instances the glands may form an abscess which points in one of the inter- 
costal spaces close to the sternum, as in a case under the care of Dr. 
Eustace Smith, or may open into the oesophagus. In one of our own cases a 
mediastinal abscess pointed near the left edge of the sternum, low down. 

The pulmonary glands which accompany the small bronchial glands into 
the lungs may become caseous, soften, and form cavities, more especially in 
the lower lobes. It must be acknowledged that caseous glands can rarely 
be diagnosed during life with anything like certainty, partly on account of 
their lying deeply, and partly from the fact that they are so commonly asso- 
ciated with chronic lung disease. They rarely attain any large size, and 
consequently do not modify the percussion note or press on the veins, bronchi, 
or nerves. 

When, however, the mediastinal glands become the seat of a new growth, 
such as lymphadenoma, the case is different ; they may become enormously 
enlarged surrounding the veins and bronchi, giving rise to marked dullness 
over the sternum and adjoining rib cartilages, and pressure signs from 
involving the vessels. Attacks of paroxysmal breathing are common on 
account of pressure on the recurrent laryngeal and other nerves. The course 
of the disease usually extends over a few- months only, the patient getting 
progressively worse. Among the early symptoms will usually be those of 
disturbed innervation. There are attacks of paroxysmal cough, with a metal- 
lic ring and stridulous breathing and orthopncea, so that the child has to 
be propped up to get its breath ; in the later stages the distress is often very 
great. The voice is altered, perhaps reduced to a whisper. The return of 
blood to the chest may be interfered with on account of the superior vena 
cava being compressed, giving rise to a distension of the jugular or axillary 
veins and swelling of the face or arms. Fluid may be present in one or both 
pleural cavities from pressure on the azygos veins. If the tumour is of any 
size, there will be dullness over the sternum or in the adjoining region, parti- 
cularly to the left edge of the sternum in the upper intercostal spaces. In- 
tense bronchial breathing may be heard here. Moreover, the lung may be 
pushed to the left by the encroachment of the tumour, which may bulge 
forward the sternum and ribs. 

Chronic Tuberculosis of the ILung-s 

Infancy and Early Childhood. — No age is free from liability to be affected 
with tubercle ; thus Demme has found tubercular disease of the intestine in 
an infant of twenty-nine days. 

Tubercular disease is not common in infants of a few months old ; at 
this period gastro-intestinal atrophy is exceedingly common, and is liable 
to be mistaken for tubercular disease on account of the wasting which takes 



Tuberculosis of the Lungs 249 

place. Tuberculosis in young children rarely begins as does the phthisis of 
adults by a growth of tubercle and a condensation at the apices of the lungs, 
and a gradual extension downwards taking place, but is apt to be far more 
widespread in its distribution both in the lungs and in the body. It is there- 
fore far more difficult to diagnose by means of physical signs which are less 
distinctive than are those of adults. It is needless to say that the same 
general appearances are found in the bodies of children as in adults dying of 
tuberculosis — grey tubercle, caseous masses, iron-grey infiltration and fibroid 
tissue in excessive quantity, and irregular cavities. The distribution, however, 
usually differs, one of the chief differences being that in adults the tubercular 
processes appear to have a special affinity for the apices ; in early childhood 
there is no such predilection, the hilus of the lung or base being frequently 
affected before the apex. The bronchial glands are almost constantly 
found caseous, with also the small pulmonary glands which accompany the 
bronchi, the latter suppurating and forming small cavities near the root of 
the lungs. In this way a tuberculosis may spread into the lungs from the 
hilus. Not infrequently one or both bases are semi-solid from caseating 
pneumonia with ragged cavities, at other times a similar state of things is 
found at the apex. In other cases both lungs are stuffed with clusters of 
grey or yellow tubercles surrounding the terminal bronchi. There may be 
tubercle on the surface of the pleura, with more or less pleurisy or small 
local empyemas. The abdominal organs are exceedingly apt to be affected : 
cheesy masses are frequently found in the liver, spleen and kidneys ; cheesy 
mesenteric glands and ulceration of the intestines are very common in cases 
of general tuberculosis. Tubercles are not infrequently found on the peri- 
toneum and other serous membranes, as the pleura and meninges of the 
brain. Tubercular disease of bone may be associated with a general dis- 
tribution of tubercle throughout the body. 

The changes found post mortem in young children suffering from chronic 
or subacute tuberculosis compared with those found in the chronic phthisis 
of adults may be summed up as follows : 

1. Frequency with which the lungs (in children) are invaded with tubei- 
cular deposits from the root of the lung in consequence of an infection from 
caseating bronchial glands. 

2. Frequency with which the lymphatic glands of the body become 
tubercular. 

3. Frequency with which caseous degeneration takes place in the lungs, 
&c, grey tubercle being less common. 

4. Frequency with which the liver, spleen, kidneys, mesenteric glands, 
peritoneum, and intestines are the seat of tubercular changes. 

5. Frequency of tubercular meningitis and of caseous tubercle in the brain. 
Symptoms. — If the diagnosis of phthisis in the early stages is difficult in 

adults, when it is possible to carefully auscultate and percuss the apices 
of the lungs, examine the sputa for bacilli, and cross-question the patient 
concerning the symptoms presented, it is necessarily much more difficult in 
the infant or young child, where the symptoms are rarely definite and where 
the lesions are so widely spread throughout the body. The younger the 
subject the more likely are the symptoms to be wanting in distinctiveness 
and the diagnosis to be consequently difficult, frequently wasting and a 



250 Diseases of the Respiratory Apparatus 

family history of tuberculosis being nearly all there is to go by. The tem- 
perature is usually hectic, normal or perhaps subnormal in the morning and 
reaching 102 or 103 in the evening, though this may be reversed. There 
may be diarrhoea without apparent cause, and various dyspeptic troubles ; 
cough, though this may be absent ; perhaps enlargement of some external 
glands. An examination of the lungs may reveal very little, perhaps some 
want of resonance over the base or apex or in the interscapular region or 
axilla, with some ringing consonant rales or crepitation. There is progressive 
wasting, which in a child of over a year or eighteen months is more sus- 
picious than in an infant a few months old, where wasting is more often 
due to chronic intestinal catarrh than to tuberculosis. In those cases where 
wasting and hectic follow measles, whooping cough, bronchitis, or broncho- 
pneumonia, there is a strong suspicion of tuberculosis, even though there 
may have been a period of comparative health intervening between the 
acute attack and the hectic supervening ; a family history of phthisis would 
make the case look still more threatening". In the later stages the sym- 
ptoms become more decisive. The hectic continues, the wasting is pro- 
gressive, the cough is troublesome, the diarrhoea perhaps is still present, 
parasitic stomatitis makes its appearance, the feet, hands, and face become 
cedematous, and the child is anaemic and very weak. Examination of 
the chest will now show some marked dullness or loss of resonance over 
some portion of lung, apex or base, with bronchial breathing and sharp con- 
sonating rales ; often one is surprised to find how little can be detected 
in the chest, even when it is evident that the child is far advanced in 
tubercular disease. The typical signs of a cavity can rarely be elicited, 
inasmuch as the cavities in the lungs of infants and young children are not 
often larger than marbles or walnuts ; most frequently they have irregular 
and ragged walls. A cracked-pot sound may sometimes be elicited in front, 
but on account of the yielding nature of the chest walls in an infant it is 
of no diagnostic value as regards a cavity. 

Diagnosis. — Whenever wasting occurs as a prominent symptom during 
infancy and childhood, tuberculosis is certain to be thought of; wasting 
occurs in all dyspeptic diseases during infancy, and it may simulate the 
wasting of tuberculosis when it occurs in connection with empyema or 
broncho-pneumonia in young children. An empyema may readily be mis- 
taken for tuberculosis of the lung if a careful examination of the lungs is 
not made, aided if necessary by an exploratory puncture, as there is wasting, 
hectic, and cough. The difficulty in deciding may be great without explora- 
tion if the empyema is localised or there is more than one. A chronic 
effusion in the pericardium may be mistaken for tubercular disease. It is 
often difficult in cases of chronic broncho-pneumonia, the chronic condition 
following an acute attack, to decide if a tubercular process is going on. 
There may be wasting and hectic, and yet after some weeks the temperature 
will gradually fall, the lung clear up, and the child perfectly recover. In 
most cases only the progress of the case will decide the question. 

Older Children. — After the age of six years — in other words, after the 
commencement of the second dentition — chronic tuberculosis much more 
frequently resembles the chronic phthisis of adults than it does before this 
era. As the child sets older the resemblance becomes still more close. 



Tuberculosis of the Lungs 25 r 

Children before this age rarely suffer from chronic tuberculosis of the adult type. 
The early symptoms are those of cough, loss of appetite, diarrhoea, wasting, 
night sweats, and hectic; progressive weakness ; the symptom which we miss 
for the most part is haemoptysis, which, though sometimes present, is much 
more frequently absent in children than in adults, and less blood i s expectorated , 
An examination of the chest may perhaps disclose some loss of resonance at 
one apex (usually the right), with perhaps some rhonchus or moist sounds,. 
or there may be no loss of resonance, only the signs of a chronic or subacute 
bronchial catarrh localised in the apex of a lung ; or there may be impaired 
resonance only, due to the presence of a thickened pleura and adherent 
lung. In this stage children perhaps more often than adults improve under 
treatment and a careful hygiene, and may be restored to perfect health; there 
is abundant evidence to demonstrate this. If the disease progresses the 
hectic and wasting continue, the child becomes pallid and weak, the diar- 
rhoea frequent and troublesome, especially following meals ; the physical 
signs show an extended area of lung involved, the tubercular infiltration 
travelling from the apex towards the base, and giving rise to caseous degene- 
ration, fibroid changes, and cavitation. The progress of such cases is apt 
to be more rapid than it is in adults, a fatal result occurring in four to 
six months. In the last stages the emaciation is extreme, the feet 
cedematous, bed sores are apt to form, and while the patient may linger 
for a while if no intercurrent affection brings the end quickly, it must be 
borne in mind that such cases are exceedingly apt to be brought to a con- 
clusion by tubercular meningitis in any stage early or late. The abdominaL 
organs are also apt to join in a more extensive spreading of tubercle than is 
the case later in life ; mesenteric disease, extensive ulceration of bowels, 
peritonitis subacute or acute, are apt to be present, and necessarily influence 
the course of the disease. Haemoptysis, which may be fatal almost imme- 
diately, occasionally occurs ; in other cases blood may be expectorated in 
considerable quantities. 

Sometimes an acute phthisis takes place without miliary tuberculosis 
being present ; the tubercular process taking the form of clusters of grey 
tubercle surrounding the bronchi, the process beginning at the apex and 
travelling towards the base, the symptoms being those of a rapid phthisis, 
perhaps extending over a month or two. 

On the other hand, a fibroid phthisis essentially chronic in its course 
may take place, appearing at times to be stationary, or the patient undergoes 
considerable improvement. In these cases there is much fibroid change and 
iron-grey induration of lung with retraction of chest. The physical signs 
develop slowly, there is dullness of an apex, which gradually becomes almos 
absolute, intense bronchial breathing, consonant rales and gradual retraction 
of the affected side. The child may fatten and appear to flourish, and present 
a normal temperature, but it is easily exhausted, suffers from dyspnoea on 
exertion, its face and lips are turgid, and the fingers become clubbed. In 
a few cases there is haemoptysis, but this is the exception. It is possible 
that the process may become arrested, the lung being converted into fibroid 
tissue. In the majority of cases the disease is progressive, and the opposite 
apex becomes affected. The whole course may extend over several years, 
unless bronchitis or some other intercurrent disease supervenes. 



252 Diseases of the Respiratory Apparatus 

The principal clinical differences between chronic phthisis in older chil- 
dren and adults may be summed up as follows : 

1. Frequency with which children in the first stage recover. 

2. Frequency with which the disease is brought to an abrupt termination 
by some acute affection, as tubercular meningitis, pleurisy, peritonitis, or 
acute miliary tuberculosis. 

3. Comparative rarity of haemoptysis in the early stages and of laryngitis 
in the latter stages. 

4. Frequency of complication with abdominal tuberculosis. 

5. Comparative rarity as compared with that of adults of extensive cavities 
in the lungs. 

The post-mortem appearances are mostly similar to those found under 
similar circumstances in adults. Irregular ragged cavities, varying in size 
from a hazel nut to a walnut, most numerous in the upper lobes, with cheesy 
masses and fibroid indurations ; the same condition in the lower lobes in 
an earlier stage, with more or less crepitant lung. As a rule there is not 
much grey tubercle, but caseous masses, sometimes associated with peri- 
bronchial grey or yellow tubercles. There are not often cavities of large 
size, but these occur at times ; in one case, in a boy of eight years, who had 
suffered for six months, there was a cavity in the upper two-thirds of the left 
lung as large as an adult's clenched fist. Pleurisy and small collections of 
pus are not uncommon. The bronchial glands are almost invariably en- 
larged and caseous. 

Instead of the above, especially in the more acute cases, the lungs may 
be everywhere infiltrated with clusters of peribronchial tubercles, which 
crowd the upper lobes, where ragged irregular cavitation is commencing, 
while they are more sparely scattered through the lower lobes. 

In fibroid phthisis an extensive portion of one or both lungs is cicatrised 
and solid, bands of fibrous tissue run across, there is much grey infiltration, 
dilated bronchi, caseous glands, and perhaps small ragged cavities. Other 
portions of lung are hypertrophic or emphysematous, perhaps containing 
scattered clusters of peribronchial tubercles. 

Cheesy tubercles are met with constantly in other organs than the lung, 
especially in the liver, spleen, and kidneys ; caseous mesenteric glands and 
ulceration of the intestines may also be associated with lung mischief. 

Treatment. — The treatment of enlarged and caseous glands is necessarily 
the same in large measure as that of early tuberculosis. If a child, say one 
from three to six years of age, suffers from a hacking paroxysmal cough, is 
slightly feverish at night, remains in a condition of ill-defined malaise, especi-. 
ally if he has recently suffered from bronchitis, whooping cough, or measles, 
the suspicion will be raised that there is either caseation of the bronchial glands 
or an early tuberculosis of the lungs. There can be no certainty about the 
■diagnosis, but if the family history points to tuberculosis there is only too 
much reason for anxiety. The indications for treatment which suggest 
themselves are to place the child under conditions in which there will be the 
least possible irritation of the lungs and bronchial tubes, and to supply him 
with nourishment in suitable quantities and in the most digestible forms. 
It is needless to say that these indications are fulfilled with difficulty or only 
partially. Residence in the smoke and dirt of large towns, or on damp 



Tuberculosis of the Lungs 253 

clay subsoils, is alike bad, and if possible the child should be removed to 
some breezy moorland site or bracing seaside place. Fresh air when it can 
be taken' without risk of cold is of the greatest possible advantage in bracing 
up the digestive organs. In winter, if it be impossible to seek a warmer 
climate, thoroughly warm and well-ventilated apartments free from draughts 
must be secured. A well-warmed but not ' stuffy ' house is a great advan- 
tage, as the child may in such a case have the ' run ' of the whole house 
without being exposed to cold passages and open windows. A nourishing, 
easily assimilated diet should be prescribed, a variety being introduced in 
order to tempt the capricious appetite often present. A cup of beef tea the 
last thing at night will often ease the cough and soothe the child to sleep. 

Of special medicinal treatment, cod liver oil, malt extract, mineral acids 
with cinchonine and the hypophosphites may be prescribed with advantage. 
Creasote or guaicol is often prescribed. Counter-irritants are useful ; they 
are hardly likely to have much effect on glands which are actually caseating,. 
but they undoubtedly favourably influence chronic catarrhs of the bronchial 
mucous membranes. Among the milder ones, the lin. pot. iodid. c. sapone 
may be rubbed into the chest every evening, a piece of l swansdown ' or layer 
of cotton wool being applied. A stronger application may be made by diluting 
lin. iodi with glycerine and water (F. 27), and applying it to the sternum 
or the subclavicular region every night and covering it over with a layer of 
cotton wool. Care must be taken not to render the skin sore by applying it 
too frequently on the same spot. 

The more urgent symptoms present when the nerves are involved by a 
mediastinal tumour — and these are often very distressing — may be relieved in 
many cases by warm applications, such as fomentations, and small doses of 
nepenthe or morphia. Relief will probably be obtained from opiates com- 
bined with ether or chloroform if the dyspnoea is due to spasm. Inhalations 
of chloroform, ether, or nitrite of amyl, usually relieve. Small doses of 
morphia given subcutaneously may be tried. 

Much that has been said applies to the early stages of all forms of chronic 
tuberculosis of the lungs. It is of the greatest possible importance to recog- 
nise the disease in its early stages, when there is a fair probability that it may 
be arrested or undergo a natural cure if the conditions are favourable. To 
this end an equable temperature, a pure bracing air, protection from cold and 
damp and rapid temperature changes are of the greatest importance. The 
presence of tubercle in the lungs naturally predisposes to catarrhs and local 
pneumonias, and exposure to unfavourable conditions likely to favour their 
development is certain greatly to aggravate the disease. Great care must 
also be taken in the food which the child takes and in treating any departure 
from a health)' condition of the child's digestive system. A condition of 
catarrh of the bowels is very often present in tubercular diseases apart from 
any local lesion, and is an important factor in producing the wasting which 
accompanies tuberculosis. 



254 The Specific Fevers 



CHAPTER XIII 

THE SPECIFIC FEVERS 

Feverishness. — Children more often than adults are apt to suffer from 
attacks of feverishness, the temperature perhaps rising suddenly without any 
obvious cause, remaining raised for a day or two, much to the alarm of the 
friends and the medical attendant, and returning to normal without any clue 
having been obtained as to the cause. Perhaps the feverishness is less acute, 
but continuous for some weeks, rising in the evening and falling in the 
morning, without any diagnosis being made. It is hardly needful to insist 
that in any given case no effort should be spared to find out the cause of 
the fever, and to effect this the child should be carefully examined, its chest 
being stripped and any sign of pneumonia carefully looked for, while the 
skin and throat should be minutely scrutinised in a good light. Inquiries 
should be made as to what the child has taken in the way of food prior to 
the attack. If the attack is sudden, the temperature rising to 103 or 104 
or more, epidemic influenza, acute pneumonia, scarlet fever, or acute dys- 
pepsia from the ingestion of unsuitable food will doubtless be suggested. 

In children under three years of age, a high temperature with convulsions 
may be due to acute pneumonia, and a careful examination of the lungs should 
be made ; in older children there may be no convulsions, but usually, if the 
physical signs are not distinctive, there is some stitch in the side felt on 
coughing, "with more or less dyspnoea. In scarlet fever there is usually 
vomiting and often diarrhoea, and the appearances in the throat and skin 
soon become distinctive. During the first twelve or twenty-four hours it 
may be difficult to distinguish between scarlet fever and an acute diarrhoea 
or gastro-intestinal catarrh the result of improper food, as sometimes a 
gastric attack will produce severe symptoms of vomiting, diarrhoea, and fever. 
Or there may be no diarrhoea or sickness and only feverishness. The 
diagnosis in epidemic influenza has often to be made from the fact that it is 
prevalent in the house or neighbourhood rather than from the symptoms, 
which are so frequently indefinite ; a temperature of 104 or 105 with convul- 
sions is not uncommon. In many of these cases it is wise to wait before 
giving a definite opinion. In infants and young children the cause of an 
unexplained high fever may prove to be an acute otitis which has been over- 
looked till pus has made its appearance at the external meatus ; such cases 
are very apt at first to be mistaken for meningitis (see fig. 36). 

In some feverish attacks we have noticed an enlargement of the cervical 
glands, either the deep cervical at the angle of the jaw, or the glands under the 
upper part and posterior edge of the sterno-mastoid, without any appearances 



Feverishness 



255 



of irritation in the tonsil or pharynx ; possibly there may be such a disease 
as an acute idiopathic adenitis, or some poison may perhaps be absorbed 
from the pharynx and enter the glands without setting up any local lesion at 
the point of absorption. 

Such cases have been described by E. Pfeififer, Heubner, and Rauchfuss, 
under the name of gland fever. The attack, according to Pfeififer, is sudden 
and the fever moderately high ; there is complaint of tenderness in the neck, 
and some of the cervical glands, usually those at the posterior border of the 
sterno-mastoid, or the occipital glands, are swollen and tender. In a few 
days the temperature falls and the glands become normal. In a few instances 
the attack has been more severe and has lasted longer. In these cases no 




■minnni HHHiumap 
giiiieii iniiiigiiiiiaiaiai a s 

minir 



.iiiiiili 

iiiiiiiii 

SSSSSSES35 

iiiiii § - 







iilLliiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiill 

lallllllllllllllllilllllll lllllllllllll 







Fig. 36. — Temperature Chart showing high temperature due to an acute otitis in an 
infant of seven months. 

abnormal appearances have been detected in the tonsils or nasal mucous 
membrane. The glands never suppurate. PfeifTer has noted several of 
these cases in one house at the same time, the disease being infectious or 
epidemic. 

We are, however, rather inclined to think that while 'gland fever' docs 
undoubtedly take place, it is rarely idiopathic, but the result of absorption of 
toxic materials from a mucous membrane. 'Gland fever' often occurs in 
scarlet fever and other various forms of tonsillitis, the throat may be 
apparently well or hardly abnormal, yet the cervical glands may be swollen 
and tender and the patient feverish. 

Acute cerebral congestion or ' sunstroke J maybe accompanied b) high 



256 



The Specific Fevers 



fever, quickly followed by death. In many cases where there are a high 
temperature and cerebral symptoms, such as coma, delirium, or torpor, it is 
often difficult to say whether there is some cerebral disease, or whether the 
high temperature and poisoned blood are not causing the cerebral symptoms 
the brain itself being normal. When the temperature rises more slowly, 
taking several days to reach its greatest elevation, as is the case in measles, 
typhus, typhoid, and smallpox, a diagnosis cannot be made for a few days, 
till characteristic symptoms develop. The hard cough, suffused eyes, and 
rash of measles, the headache, delirium, and coma of typhus, the backache, 
and papules of smallpox, settle the diagnosis. This is sometimes the case 
in erythema nodosum ; there are some few days of fever with no definite 



Hiiiiiiiiiiiiiiiii 




lilllillllii 

ililllllllil 



llliiiL 
lliiiiii 
lillllllililii 
lilillilRfiilillll 



iiliriifililililiiiiiliiiii 

liiiiiiMimmii 

ill 




Fig. 37. — Temnerature Chart of a case of Erythema Nodosum. The girl was in hospital convalescent 
from Acute Pneumonia. The cause of the fever was unknown till a number of typical nodes made 
their appearance. . 

symptoms, and then the characteristic red flattened nodes make their 
appearance ; see fig. 37. 

The diagnosis as to the cause of fever is often very difficult when the 
fever assumes the intermittent or remittent type, going on for some days or 
weeks without any characteristic symptoms developing. Such cases were 
formerly designated 'low' or 'continued fever,' and while it is not wise to 
use such indefinite terms, we must be prepared to find cases of intermittent 
fever in children in which it may be quite impossible to make a diagnosis. 
A sub-acute or chronic gastro-intestinal catarrh, creeping pneumonia, a low 
form of enteric fever, a tubercular peritonitis or a miliary tuberculosis, may 



Scarlet Fever 257 

be present. There may be, as Dr. Foxwell suggests in these cases, a 
condition of general catarrh, including both alimentary and respiratory 
tracts. In all such cases a most careful examination should be made of the 
chest, abdomen, and retina for miliary tubercles, in the hope of detecting 
something which will throw light on the attack. We must not forget that 
some of these cases of protracted remittent fever are in reality cases of 
miliary or local tuberculosis in which healing eventually takes place. We 
feel sure we have seen such cases. 

Scarlet Pever 

Scarlet fever is a specific fever of a highly infectious and dangerous 
character which occurs in epidemics, but is always more or less endemic in 
large populations. It is easy to understand the occurrence of epidemics in 
a small population where the fever exhausts the soil, as it were, by attacking 
all those susceptible to its influence and then disappears for a while, to 
prevail at a later period, when the infection is re-introduced and the popu- 
lation contains again a number of the unprotected. It is more difficult, 
however, to understand the cause of epidemics in large cities where the 
infection is always present, unless we assume the existence of some un- 
known influence which favours the spread of the disease at one time more 
than another by rendering those who are unprotected by a former attack more 
than usually susceptible to the infection. Thus epidemics of scarlet fever are 
more common and widespread in the autumn than at any other period, and 
it would appear that at this season either the poison is apt to be more intense 
or individual susceptibility greater. Individual susceptibility varies greatly 
with age ; infants under six months of age are rarely attacked, during the 
second year the susceptibility is greater, while children during their fourth 
and seventh years are most often attacked. The susceptibility then appears 
to diminish as age increases, though, as already remarked, varying strangely 
from time to time. Thus it may happen that a medical man or nurse may 
come in contact with scarlet fever cases for weeks or perhaps months with- 
out contracting the disease and yet finally take it. In one case which came 
under our notice a probationer nurse was engaged in nursing in a scarlet 
fever ward for six months without being attacked ; many months after, while 
nursing in a surgical ward at another hospital, she contracted a smart attack 
of scarlet fever from a sporadic case arising in the ward. In another case 
a child had a severe attack of scarlet fever twenty-nine days after admission 
to the scarlet fever ward. In this case it was supposed to have had an attack 
of scarlet fever for which it was sent in ; but second attacks of scarlet fever 
are rare ; they do, however, undoubtedly occur, as in the following case : 

Scarlet Fever ; second attack. -Thomas R., aged 6 years. Vomited June 26, rash 
■noted same day; admitted to hospital June 29. There was a well-marked rash, the 
tonsils were swollen, with patches of exudation ; there were two or three degrees of fever 
for a few days. Diseharged August 20. He vomited August 21 ; admitted August 25 
with a typical attack of scarlet fever. There was a well-marked rash, tonsillitis, and 
fever. 

Scarlet fever is apparently not so infectious as measles— a large number of 

•children and adults escape being attacked ; thus Biedert found in an epidemic 



258 The Specific Fevers 

which prevailed in an isolated village (Xeunhofen, where the inhabitants 
freely mixed with one another, and where no isolation of the fever patients 
was possible, that about 58 per cent, of the children unprotected by a former 
attack contracted the disease, though only about two-thirds of these had well- 
marked symptoms, the rest having sore throats only. In different epidemics 
the number attacked varies extremely. 

The mortality varies in different epidemics : thus, in the fever ward of 
the Children's Hospital, Manchester, it has varied from 6 to 25 per cent, m 
different years during the years 1877-87, the average mortality among 1,598 
cases treated being ir8 per cent. During the seven years 1888-1894 
(inclusive) 1,015 cases were treated with an average mortality of 8 -6 per cent. 
This average mortality closely corresponds with the figures given by Collie 
of the mortality in the London, Stockwell, and Homerton fever hospitals,, 
where, in upwards of 10.000 cases of scarlet fever, the mortality was 12-5 
per cent. As in all probability many of the milder cases of fever never- 
come into hospital at all, 10 per cent, mortality given by W. Squire as the 
average appears to be as nearly correct as possible. Age influences the 
mortality very considerably ; the mortality is high during the first three or 
four years of life, amounting to 25 to 30 per cent. ; it continues high till the 
age of six or seven years is reached, declining after this till the age of 
twenty-one. again increasing after this epoch. 

Are there any morbid conditions of body which predispose to scarlet 
fever ? Very little is definitely known about such conditions : individual sus- 
ceptibility varies in the most erratic manner, at least is governed by no known 
laws, and it cannot be said that ill health in any way either favours or protects 
from attacks. To this, however, must be added that it is our experience that 
operation cases and surgical cases with open wounds are more liable to con- 
tract the disease than are healthy children. The so-called surgical scarlet 
fever is simply scarlet fever occurring in a surgical case (vide infra). 

The strong and healthy appear to be as frequently attacked as the 
weakly, and the attacks are often fatal to such ; it is by no means uncommon 
to see on the post-mortem table children who have succumbed to malignant 
scarlet fever looking fat and plump, and who were apparently in the best of 
health when attacked. 

The transference of infection from the sick to the healthy takes place in 
various ways ; it may be by direct contact, the breath or the exhalations from 
the fever patient may be inhaled, or it may be carried by means of clothes 
or wearing apparel or bedding which has been in contact with the sick. It 
is highly probable also that the excretions of the patient are infective, the 
urine, faeces, and discharges from the ear or nose. From the investigations 
of Power and Klein it seems that the fever may pass from cattle to man by 
means of the milk of cows suffering from a form of bovine fever known by 
the name of ' sore teats/ The poison of scarlet fever appears to retain its 
vitality for many months, fever breaking out again and again in houses 
which have been imperfectly disinfected. 

Incubation. — Mostly two to five days, though it may be much less, perhaps 
only a few hours ; forty-eight to seventy-two hours is a common period, but 
in many cases where slight sore throat precedes for some hours the more 
definite symptoms it is impossible to state the period of incubation with. 



Scarlet Fever 259 

exactness. In the majority of cases, if the initial vomiting be taken as the 
first symptom, it will be found that the incubation is under three days. It 
cannot be said with certainty that it may not be more than five days, but 
such cases must be very exceptional. 

Premonitory Symptoms. — The invasion in the case of children is usually 
sudden, the first symptom being" nearly always vomiting ; this may come on 
after a hearty meal. There may also be diarrhoea. In older children and in 
adults there is usually nausea if not vomiting, sore throat, headache, shivering, 
and loss of appetite. ' Sore throat ' with vomiting in a child or adult is ex- 
tremely suspicious of scarlet fever, especially if fever is present. The tempe- 
rature usually runs up quickly to 103 or 104 , and perhaps the patient sits 
over the fire on account of feeling chilly; in some cases there is slight 
delirium. 

An attack of vomiting and diarrhoea coming on suddenly with feverishness 
(io3°-io4° F.) is very probably the commencement of scarlet fever, and in 
such cases death may take place within twenty-four hours of the onset. 

Sympto7ns a?id Course. — Medium Forms. — The premonitory symptoms 
are usually followed within twenty-four hours by the characteristic rash. 
This is said to make its appearance first about the neck, but there is no cer- 
tainty about this, and traces may be seen of it on the backs of the hands and 
wrists, or on the thighs or abdomen, when it is present nowhere else. In 
some cases it is first visible on the back. At first the rash is faint though 
perfectly characteristic, taking two or three days to reach its height. In 
other cases it disappears in the course of twenty-four or forty-eight hours, 
having at no time been more than a fine faint rash. When typical it 
cannot be mistaken for any other rash. Viewed from a short distance, the 
whole body excepting the face is of a uniform bright red colour ; examined 
closely, it consists of a multitude of red points which correspond with the hair 
follicles; these points are surrounded by zones of erythematous redness which, 
joining with one another, give a general diffuse red appearance to the skin. 
Sometimes the rash consists of the points only without the erythema ; in this 
case the redness is necessarily less vivid. In rough skins the rash may be 
coarsely punctiform ; that is, there is a condition of ' goose skin,' each point 
being large and the rash therefore coarse. Sudamina are not uncommon. 
In other cases the rash is patchy on the limbs, and when this is so, the case 
may simulate measles; the patches consist of clusters of fine papules or points 
with much surrounding erythema, while normal skin is present between the 
patches. Sometimes the rash is hemorrhagic, minute extravasations of 
blood taking place into the skin ; this may occur in mild cases. It is, how- 
ever, much more common in malignant cases. Purpuric patches arc not 
uncommonly found after death that were not present during life. Towards 
the end of the first week the rash, which has been fading for several days, is 
succeeded by desquamation, which is free or slight according to the intensity 
of the rash. This exfoliation of the epidermis generally goes on for many 
weeks, being present longer about the hands and feet. The tonsils are red. 
swollen, and covered with an excess of mucoid secretion, yellow points 
corresponding to the tonsillar crypts are usually present, sometimes there 
are patches of yellow exudation: the soft palate, uvula, and pharynx are more 
or less congested. The nasal mucous membrane is frequently involved, so 



26o 



The Specific Fez 



ers 



that there is much discharge from the nose. The deep cervical glands at 
the angles of the jaw are usually enlarged. The tongue is coated with a 
thick white fur ; not infrequently there is a dry glazed central band on the 
dorsum ; in the course of a few days the tongue cleans, leaving a red clean 
glazed tongue with prominent fungiform papilla; — i.e. ' the strawberry tongue.' 
The eyes are often suffused and the conjunctivae injected, and with this there 
is often sleeplessness or delirium, no doubt due to a congested state of the 
membranes of the brain. In rare cases the delirium is severe and the 
patient violent. 

The pulse is quick, varying from 1 20 to 1 50, often faster than the temperature 




Fig. 



Temperature Chart of a case of Scarlet Fever, medium attack. 
*, Rash present. 



M. K., aged 13 years. 



or the general state of the child would have led one to expect ; the tempe- 
rature varies, mostly reaching 103 or 105 in a moderately sharp attack 
(fig. 38). The urine is scanty, high-coloured, and often contains a small 
quantity of albumen. In the course of a few days, perhaps by the end of the 
third or fourth, the attack has reached its height, and the symptoms begin to 
decline. The rash gradually fades, the temperature falls, the evening rises 
being smaller and the morning remissions more marked ; the tongue cleans, 
the fauces are less injected, and the appetite returns. By the end of the first 
week the temperature has reached normal ; any feverishness which continues 
after this suggests some complication, the commonest being an ulcerating or 
sloughy process going on in the throat, inflammation of glands, and otitis. It 



Scarlet Fever 



261 



must, however, be added that attacks of scarlet fever are extremely unequal 
and no two cases are exactly alike. 

Mild Scarlet Fever. — In some cases the premonitory symptoms are 
absent or the fever is only slight and easily overlooked, and the first thing to 
call attention to the attack is the rash. It not unfrequently happens, even 
in hospitals where the children are under observation, that the discovery of a 
rash is the first thing noted. The child may seem to be in its usual health, 
make no complaint of sore throat, and appear to take its meals well, with 
an evening rise and a morning remission of temperature, and yet be suffer- 
ing from a mild attack of scarlet fever (fig. 39). The rash in such cases 
is rarely well marked, but if it is diffuse and punctiform and remains visible 
for twenty-four or forty-eight hours, the attack is unmistakably one of scarlet 
fever. There is usually slight tonsillitis. The most difficult cases to dia- 




Fig. 39. — Temperature Chart of a Mild Scarlet Fever. B. W., aged yea' 
Attack contracted in scarlet fever ward. 



gnose are those where there is sore throat without rash, inasmuch as there 
is nothing characteristic about a scarlatinal tonsillitis. 

Malignant Scarlet Fever. — In some cases death occurs very rapidly, 
perhaps within twenty-four hours, though this is rare. The most rapid case 
which has come under our notice was that of a girl of twenty months. 

Scarlet Fever rapidly fatal.— -She was noticed not to take her dinner well, and vomited 
after her tea ; her temperature, which had been normal in the morning, had risen to 103 
b y 5-3° (fig- 4 oa ) ; at 7 P.M. the pulse was 160, the tonsils were enlarged, and there was 
a very faint rash over the body ; she was removed the same evening by the resilient medica! 
officer, Dr. Kershaw, to the lever ward. Next morning the rash had disappeared, the 
tonsils were enlarged with a patch of exudation on one of them, her pulse ami respirations 
were rapid, but she did not seem extremely ill. She gradually became worse, the face 
cyanosed, respiration gasping, and pulse failing; she died soon after 5 I'M., twenty fot.r 
hours after the initial symptom of vomiting. 

At the post-mortem one tonsil was sloughing and soft. Death in this 
case, as in most rapidly fatal cases, took place through the heart failing 



262 



The Specific Fevers 



under the influence of the poison ; they may not appeal for a few hours in 
actual danger, then symptoms of cyanosis and collapse set in, quickly followed 
by a fatal result. In the great majority of acute cases death does not take 
place till the fourth or the seventh day (fig. 40 b) ; in these the temperature 
is high, perhaps 105 or 106 , there is much diarrhoea, often extreme restless- 
ness, followed by coma ; the tonsils are much swollen and covered with foul 
secretion, there is much nasal discharge, the glandular swelling and cellulitis 
are great, the neck being hard and tense to the touch ; the skin is of a dull 
lurid colour, the extremities cold, and the heart gradually fails. If life is 




i 



!! 



ril 
II 



HUH 
limn 

H«afc1!HI 

BISKS 
isislss 
ill | 



ssss 

sisl 



Hiss 



Illillllill 



I 



liliiiiii 
Ililililll 



Fig. 40 a.— Temperature Chart of Malignant 
Scarlet Fever. Death in twenty-four hours. 



Fig. 40 £. — Temperature Chart of Malignant 
Scarlet Fever. Death seventh day. *, Rash. 



prolonged for a few days the tonsils and soft palate slough and the lungs 
become the seat of septic pneumonia. In another class of cases in which 
life is prolonged to the end of the second or third week a condition of 
septicaemia is set up. The tonsils ulcerate, sloughy patches appear on 
the fauces, the glands become enlarged and brawny, the nasal mucous 
membrane discharges a purulent secretion, and the conjunctivae become 
affected ; the temperature is remittent but continues high, the urine albu- 
minous, pus wells out from both ears, the child gradually wastes, and dies 
in the course of ten or fourteen days. At the fiosi-jnortem there are found 
extensive sloughing about the fauces, pleuro-pneumonia, and large haemor- 



Scarlet Fever 263 

rhagic kidneys with minute abscesses. In some cases the temperature remains 
high during the second or even third week without any local lesion being 
discoverable to account for it. In all such cases the lungs should be carefully 
•examined, and the possibility of some septic inflammation going on in the 
kidneys should be borne in mind. 

Prognosis. — A guarded prognosis must always be given in the case of 
young children, the throat complications in these being generally serious. 
The tonsils are apt to slough, and they have so little power to get rid of the 
foul secretion which rapidly forms in the pharynx and nose that they are ex- 
tremely liable to pneumonia from extension from the pharynx and glandular 
inflammation. Diarrhoea is always a serious symptom ; when present at the 
-onset it points to a sharp attack, in the later stages it is also of evil augury, 
and if a marked symptom it usually presages a fatal result. Drowsiness at 
the onset and during the course of the attack is an unfavourable symptom, as 
it usually accompanies a high degree of fever and a severe course. In all 
cases where the temperature is maintained during the second or third week 
the prognosis must be exceedingly guarded, and the possibility of a fatal 
nephritis supervening must be borne in mind. 

Complications and ' Sequelce. — Many of these have already been referred to : 

( 1 ) The tonsils may become deeply excavated, the soft palate may slough, 
a small hole appearing through the velum, to be followed perhaps by an 
almost entire destruction of the soft parts ; in the rare cases when recovery 
follows, cicatrisation and deformity of the soft palate are the result. The 
inflammation may spread to the epiglottis and larynx, and croupy symptoms 
become so urgent that tracheotomy is required. The fauces and larynx may 
become the seat of false membrane. In rare cases the ulcerating process 
in the throat may reach and enter the internal carotid or jugular vein and 
death follow from haemorrhage. 

(2) The nasal and conjunctival mucous membrane may be the seat of 
inflammation or a fibrinous exudation. A chronic discharge from the nose 
and a consequent eczematous condition of the upper lip may be left after the 
fever. 

(3) Otitis. — The inflammation may spread along the Eustachian tube to 
the middle ear, and pus be formed in the tympanic cavity, which finds its 
•exit by perforation of the membrane. This may happen during the fever or 
during convalescence. We have known it occur as early as the fourth day, in 
other cases when convalescence is well established. Suppuration in the tym- 
panum is one of the common causes of a continued elevated temperature 
after the disappearance of the rash ; the child may suffer very little pain, and 
the presence of pus in the external meatus or staining the linen may be the 
first thing to call attention to this complication. At other times the child 
will put its hand to its ear and frequently shake its head, as if to get rid ot 
some source of irritation. Pyaemia and abscesses in the lungs may follow if 
thrombosis of the lateral sinus occurs. 

(4) The cervical glands frequently become enlarged and suppurate, 
either during the course of the fever or when the child is convalescent In 
some cases, more especially in weakly children, much sloughing may go on 
about the neck, deep ragged ulcers being formed, exposing the large vessels ; 
fatal haemorrhage may occur from the latter. 



264 The Specific Fevers 

(5) Broncho- or pleuro -pneumonia occurs very frequently during 
the second week, and is due to extension downwards of the lesion from- 
the throat. Pneumonia followed by empyema may take place during con- 
valescence. 

(6) Synovitis and Rheumatism. — -The joints are apt to become swollen 
and tender at the end of the first or beginning of the second week ; those 
most frequently affected are the wrists and small joints of the hand, whilst 
sometimes the synovial sheaths of the tendons at the back and in the palms 
of the hands are attacked. The knees, ankles, soles of the feet, elbows, and 
joints of the cervical vertebrae may be affected. Movement of the affected 
joints causes pain, and they are mostly swollen, red, and tender. The affec- 
tion is rarely severe, being fugitive, and seldom returning to the same joint. 
The knees sometimes remain swollen for some weeks from effusion into- 
the joints. The cases complicated with synovitis are usually severe, though 
exceptions occur. Peri-endocarditis occurs much less frequently than in the- 
ordinary form of rheumatism. Synovitis sometimes occurs in association, 
with nephritis during the second week. Attacks of true rheumatism are apt 
to occur during convalescence, but such are more common in young adults- 
than in children ; these attacks differ in no particular from ordinary rheu- 
matism, the heart being frequently involved. An attack of scarlet fever during 
convalescence from rheumatism not infrequently causes a relapse. 

(7) Pyaemia and suppuration in the joints occasionally occurs ;. 
any joint may be affected. Such cases are mostly fatal, though not 
invariably so. 

(8) Pericarditis or endocarditis may occur without joint pain or 
nephritis being present. 

(9) Nephritis. — -No complication of scarlet fever can vie in importance- 
or interest with nephritis ; and this condition often gives rise to much anxiety 
in an otherwise mild and favourable case. The ' initial ' albuminuria which 
frequently accompanies the febrile state in the first week of the disease is not 
of much importance, as it is usually temporary and not due to any important 
lesion of the kidneys, and quickly disappears as the fever subsides towards 
the end of the first week. Apart from this febrile albuminuria, there are two 
forms of nephritis which, it is important to bear in mind, are distinct from 
one another, though they have frequently been confounded and much con- 
fusion has arisen in consequence. They may be distinguished as (a) Septic 
nephritis, (b) Post-scarlatinal nephritis. 

{a) Septic Nephritis. — In the severe forms of fever complicated with 
sloughing tonsils and soft palate and much glandular swelling the urine is 
albuminous, frequently highly so ; but it rarely contains blood in appreciable 
quantities or casts ; there are indeed no renal symptoms, or if there are 
they are so masked by the general condition of septicaemia that it is difficult 
or impossible to differentiate them. There is no dropsy or uraemic pheno- 
mena. If the patient survive till the end of the second or third week, a 
more or less typical pyaemic kidney is found at the post-mortem. The 
kidneys are enlarged, frequently very much so ; they are flabby, of a cream 
colour on the surface, with minute haemorrhages and usually minute ab- 
scesses. On section the cortex is of the same cream colour mottled with 
injected vessels and points of fluid or inspissated pus. This condition of 



Scarlatinal Nephritis 265, 

kidney forms part of a general condition of pyaemia, and is chiefly of interest 
in demonstrating that the kidneys suffer during the course of the disease 
itself, and consequently in cases which recover are in a condition which pre- 
disposes to inflammatory affections during convalescence. 

(b) Post-scarlatinal Nephritis. — This is the form which is liable to super- 
vene during the third or fourth weeks, and which is known generally by the 
name of scarlatinal nephritis. There can be little doubt that the kidneys arc- 
actively engaged during the course of the fever itself, and for the succeeding 
week or two, in carrying off the waste products formed during the fever, and 
are in an irritable condition and prone to take on inflammatory action, in 
the same way as the bronchial tubes and lungs are left in an irritable con- 
dition after measles and are apt to suffer from inflammatory attacks : and 
while it is possible in both cases that nephritis and pneumonia may super- 
vene in spite of the greatest care, yet any chill or exposure to cold is extremely- 
likely to produce or determine such an attack. The number of those who 
suffer varies in different epidemics, and also according to the season and' 
the care which is taken of them during convalescence. Taking an average 
of several years, we find about 6 per cent, of our hospital patients have 
suffered from post-scarlatinal nephritis. Patients who have had the primary 
fever both in a severe and mild form may be attacked ; in the former class 
of cases, especially where there has been no period of apyrexia, it is mostly 
fatal ; in the latter class — at least in hospital — it is rarely so fatal. The 
prognosis is usually bad in those cases where the temperature continues 
elevated during the second week, in consequence of severe pharyngeal or 
glandular inflammation, and which contract nephritis in the third week, the 
latter complication supervening on the throat lesions. From the fourteenth 
to the twenty-sixth day is the commonest time for nephritis to supervene, 
but as it usually begins insidiously, traces of albumen being - present for a 
few ; days before blood and larger quantities of albumen appear, it is often 
impossible to determine the exact date of the commencement of the attack. 
In well-marked cases it is noticed by the attendants that the child which v 
since the subsidence of the fever, has been practically well, becomes restless, 
feverish at night, thirsty, has a quick perhaps hard pulse, and passes small 
quantities of dark-coloured urine. If particular attention has been paid to 
the urine, it will probably have been found that it has been diminishing in 
quantity, and has contained small quantities of albumen for a few days prior 
to the dark urine being passed. Sometimes puffiness about the face pre- 
cedes the appearance of albumen in the urine. The urine may be dark 
red, but usually it is 'smoky, 1 and on allowing it to stand in a tall glass 
deposits a dark flocculent precipitate, not unlike the flocculi in beef tea. This 
precipitate consists of blood corpuscles, epithelium and fibrinous cylinders 
which have been formed in the tubules and consequently may contain 
corpuscles and epithelium. The supernatant liquid contains a variable 
amount of albumen, sometimes becoming almost solid on being boiled ; 
more often a half to a sixth of its volume of coagulated albumen pre- 
cipitates by boiling. It may not contain any blood. For a tow days the 
urine continues dark anil albuminous and of high specific gravity (1020 1, 
and diminished in quantity, perhaps only a few ounces per diem ; the face 
becomes pale and puffy, there may bo oedema of the foot and scrotum, 



266 



The Specific Fevers 



more or less vomiting ; then, perhaps, at the end of a week an improvement 
takes place, large quantities of urine are passed with diminished quantities 
of blood and albumen, and the child becomes again convalescent, though 
the urine may contain some albumen for weeks or even months, and the 
■anaemia may continue for a like period. On the other hand, in a minority of 
cases the nephritis is prolonged and symptoms of uraemia may supervene, 
the pulse becomes slow, the temperature subnormal, the tongue dry and 
brown. Often there is frequent vomiting, sometimes diarrhoea (see fig. 41) ; 
haemorrhages may take place from various surfaces, especially the nose ; 
there may be amaurosis, muscular twitchings, and perhaps general con- 
vulsions. 

In all cases of nephritis particular care should be taken to examine the 
heart, inasmuch as a fatal result is more often brought about in consequence 
of cardiac failure than directly through uraemic convulsions. One of th e 




Fig. 41. — Temperature Chart of Post-scarlatinal Nephritis, 
convulsions. Recovery. 



"% rash ; a, albumen ; c, uraemic 



effects of nephritis is to raise the tension in the blood-vessels, and this, it 
continued for any considerable time, is followed by dilatation of the heart, 
the tension in the arterial system in combination with malnutrition being- 
responsible for this result. Another not uncommon result is endocarditis 
or pericarditis, and possibly embolism. The possibility of death occur- 
ring- suddenly during the course of an acute or subacute nephritis must 
always be borne in mind ; the patient may appear to be doing fairly well, 
perhaps sitting up in bed and playing with his toys, when an attack of 
dyspnoea comes on, the face becomes livid or pallid, the pulse disappears, and 
death quickly takes place. Sometimes attacks of dyspnoea may precede by 
a day or two the fatal event. Such cases have been often described as being 
fatal in consequence of oedema of the lungs, the dilatation of the heart 
having been overlooked ; oedema of the lungs is present, but it is secondary 
to the cardiac failure. The pathology of such cases is tolerably clear ; acute 
nephritis, running a very rapid course in consequence of the kidneys being 



Complications of Scarlet Fever 267 

almost completely choked, usually terminates with uraemic phenomena ; if 
it runs a slower course, the tension in the blood-vessels throws additional 
work upon the heart, the left ventricle struggles with the increased work 
thrown upon it, the blood becomes impoverished and nutrition impaired, 
the cavities of the heart dilate, and finally that organ gives way, often 
suddenly at the last. The amount of dilatation present should be care- 
fully noted by the position of the apex beat, and the increase of impaired 
resonance. 

Pneumonia, pleurisy, and peritonitis may occur in the course of 
nephritis, and pleuro-pneumonia, ending in gangrene, may take place. In a 
few cases the attack is exceedingly acute, the temperature being high, 104 
to 105 , the tongue dry and brown, the urine containing much blood and 
albumen, and death rapidly taking place. In such cases there is usually 
coincident pneumonia. In a large number of cases the attacks are mild, 
a small quantity of albumen, perhaps without any blood, making its appear- 
ance during the third week, the face becoming puffy and the child anaemic, 
the albumen disappearing in the course of a week or two, and the child after 
a prolonged convalescence slowly regaining its health. 

Total suppression of urine is not common, a few ounces daily being 
usually passed ; in one of our cases only three ounces of pale albuminous 
urine was passed in the four and a half days which preceded death ; there 
were no convulsions. Life is rarely prolonged beyond the fifth day if there 
is total suppression. Death takes place in many cases without convulsions ; 
in others convulsions may supervene and recovery follow ; the convulsions 
are not dependent only upon retained urinary products, but also upon the 
stability of the nervous centres, which differs markedly in different children. 

Diagnosis. — The diagnosis of mild cases of scarlet fever often presents 
extraordinary difficulty, and yet the importance of making a diagnosis is often 
great. In hospital or dispensary practice cases have mostly to be treated as 
infectious or non-infectious ; as there is often no opportunity of taking a 
middle course, they must be sent into a fever ward with the risk of contract- 
ing the disease if the diagnosis is at fault, or of infecting others if treated 
with non-infectious cases. In private practice among the wealthier classes 
it may be possible to isolate all suspicious cases, but such are always a source 
of anxiety. It cannot be too forcibly impressed that diagnosis in some 
instances is impossible, and that errors will occasionally be made by the most 
•experienced, though at the same time it must be acknowledged that mistakes 
arc more frequently made through carelessness than from any want of know- 
ledge. The most characteristic phenomenon is of course the rash, and if this 
is well marked, being diffuse and punctiform, and lasting at least twenty-four 
•or forty-eight hours, even in the absence of tonsillitis or a high tempera- 
ture, there can hardly be a doubt about the diagnosis. A measles rash can 
hardly be mistaken for it, except in those cases where the rash is patchy about 
the limbs, but in these it is usually diffuse and characteristic on the trunk. 
A scarlet fever rash, however faint, usually lasts for twenty-four hours at least, 
in this respect differing from erythematous rashes, which may be present in 
the evening and gone before morning. It Is always well when called to see a 
rash b)' artificial light to wait for daylight to give a definite opinion. h IS 
important to bear in mind that a rash more or less resembling scarlet fever 



268 The Specific Fevers 

occurs in some cases of pyaemia and septicaemia, also in diphtheria (which, 
when it occurs, is septic), influenza, and rubella. A red rash is sometimes- 
caused by belladonna, arsenic, and quinine. To distinguish between 
scarlatinal and simple tonsillitis is mostly impossible in the absence of a 
rash ; the ' strawberry ' tongue is generally absent in cases unattended with 
a rash. Cases of tonsillitis where the nasal mucous membrane becomes 
involved, or where there is excessive exudation on the fauces or sloughing of 
the soft palate, if diphtheria can be excluded, are probably scarlatinal. If the 
lymphatic glands at the angle of the jaw become enlarged and tender, scarlet 
fever is probable. Acute nephritis occurring after an anomalous rash or 
sore throat makes it practically certain that the primary attack was scarlet 
fever. 

Morbid Anatomy. — In the bodies of those dying during the first few days 
of the disease, no gross lesions except those in connection with the throat 
can be detected. One or both tonsils are ragged, perhaps sloughy, the glands- 
are enlarged, perhaps beginning to suppurate, the internal organs are gorged 
with blood, there are minute haemorrhages on their surfaces. The heart,, 
liver, and kidneys are pale, the Peyer's glands are swollen, and the mucous 
membrane of the intestines injected. If the child has survived a week or 
more, usually septic changes are present ; the lungs are in a condition of 
pneumonia more or less advanced, which is secondary to the sloughy throat 
and the glandular inflammation and cellulitis in the neck ; marked changes 
are also found in the kidneys if the child has survived two or three weeks. 
In typical cases these are much enlarged, flabby, pale on the surface, with 
minute haemorrhages and injected capillaries ; on section minute abscesses 
may often be seen at the base of the pyramids. On microscopical examina- 
tion large tracts of kidney substance will be found infiltrated with leucocytes, 
and micrococci (Streptococci pyogenes) will be detected in the capillaries. If 
death has been the result of post-scarlatinal nephritis, in the early stages the 
kidneys will be gorged with blood and deeply stained in consequence of the 
tubules being choked with casts and the capillaries distended to their utmost. 
In a later stage the kidneys are enlarged and pale, dripping urine on section, 
and on close examination it will be noted that the Malpighian bodies are 
enlarged and pale, standing out prominently like grains of sand dusted on to> 
the cortex. On microscopical examination it will be found that the glomeruli 
are enlarged in consequence of containing an increase in the number of their 
nuclei, in some cases fibrinous thrombi, and in a later stage being surrounded 
by a fibro-cellular growth which completely strangulates them and produces, 
complete obstruction. When nephritis is present the cavities of the heart 
are found dilated ; sometimes there is peri-endocarditis, peritonitis, or pneu- 
monia. 

No specific micro-organism has been discovered in cases of scarlet fever r 
yet we cannot doubt that such exists. One of the reasons for its non- 
discovery is in all probability that it will not grow on any of the ordinary 
cultivation media. There is no difficulty in cultivating various pus cocci 
from a drop of blood taken from the finger of a scarlet fever patient, but 
this is also true of measles and other febrile diseases. 

Treatment. — As soon as scarlet fever is suspected, means must be adopted 
to prevent the spread of the disease in the household by isolating the patient 



Scarlet Fever 269 

as far as it is possible to do so. It is obviously impossible to effect this in the 
smaller class of houses, and indeed even in- large and well-appointed houses 
nothing like perfect isolation can be carried out, the removal of the patient to 
a fever hospital being in all cases the wisest course when it can be managed. 
To diminish risks of infection as far as it is possible, a room on the upper 
story should be secured, or, still better, the whole of the top landing should 
be devoted to the patient and those of the household who are in attendance 
on him. Every article in the room which can be spared, especially cur- 
tains, carpets, and other woollen goods, should be removed, only retaining 
such as are required for immediate use. The bedding should consist of a 
horsehair mattress and warm but light coverings. The sick-room should 
be large and airy, the more cubic space the better, provided it can be kept at 
a moderate temperature, and all draughts avoided. The attendants on the 
sick should not mix with the other members of the household, but devote 
themselves entirely to the work of the sick-room. If there are children in 
the house who have not had scarlet fever, the question will arise what is best 
to be done with them. In the first place, it is clear that they must not attend 
school or mix with other children ; the question of sending them away must 
depend upon various circumstances. Remaining at home unquestionably 
involves a risk, and at any time so long as the house remains infected they 
may be attacked. Sending them away involves the risk of their being incu- 
bating at the time, and of conveying the infection to another household. 
The best course, if it can be taken, is to send them away to some household 
where there are no children, and whence they can be brought back if they are 
attacked after removal. To send them away to distant seaside lodgings 
could not be sanctioned under any circumstances ; it is better to run the risk 
•of infection at home, than have them sicken away from home among 
strangers, and become the source of an outbreak elsewhere. 

As soon as the diagnosis of scarlet fever is made the child should be put 
to bed, and remain there as long as there is fever, or, still better, for three 
weeks, though this, in mild cases especially, is difficult to enforce in private 
practice. In hospital practice three weeks in bed is the ordinary rule ; the 
object of this being to obviate the risk of catching cold, and it is better to 
be over-cautious in this respect. The diet for the first few weeks should 
consist largely of fluids ; it is most important that the digestive organs should 
not be overtaxed and that the excretory apparatus, especially the kidneys, 
should be active, inasmuch as the waste products are increased during fever, 
and the poison also passes out of the body in this way. During the febrile 
period, milk and barley water or milk and soda water is the best food that 
can be given ; feverish children rarely care for beef tea, and all jellies and 
meat extracts are unnecessary. One or two pints of milk suitably dilated 
during the twenty-four hours will be quite sufficient ; if more is attempted, 
sickness may not unlikely be produced. Daily sponging with tepid or cold 
water, to which some Condy's Fluid or other deodorant is added, is of much 
service. Caution should be exercised in giving baths, and unless the bath 
can be brought to the bedside, they hail better be avoided until convalescence 
is well established. Whilst desquamation is proceeding, after the spongings 
or warm baths the skin should be gently anointed with glycerine and starch, 
weak carbolic oil, or ung. lanolini with carbolic acid or eucalyptus. 



270 The Specific Fevers 

We have no belief whatever in the possibility of rendering the patient 
entirely free from infection by anointing the skin. We believe the infection 
of the fever may leave the patient by means of his breath and also by the 
urine. 

The application of topical remedies to the throat and nasal mucous 
membrane is frequently a matter of great difficulty in children, and much 
adroitness and firmness will be often required. In mild cases where there 
is only a slight congestion and swelling of the tonsils, no local treatment 
need be attempted, except perhaps the sucking of pieces of ice or iced milk. 
In older children the throat spray may be used if the patient is sufficiently 
docile, but young children are almost sure to offer a certain amount of 
resistance when their throat is being attended to, and under these circum- 
stances spraying is useless, and the spray is rarely properly directed. Here 
mopping by means of a large paint brush or lint secured at the end of a 
piece of stick will have to be resorted to. Syringing the fauces is also useful 
to clear away the mucus which is so apt to accumulate both in the fauces 
and nasal passages. 

In selecting an antiseptic which is to be used freely as in syringing or 
spraying, it is well to remember that some of it may be swallowed, and 
consequently it should not be very poisonous, while for mopping or painting 
a caustic or more active poison may be used. In severe cases the frequent 
cleansing of the throat is a matter of great importance and one upon which 
we are inclined to lay much stress ; it is, however, often attended with 
exhausting struggles for the patient, and can only be done by properly 
trained nurses, the friends rarely having the necessary skill or firmness. 
The actual antiseptic selected is of less importance than the manner of using 
it, the object being to prevent the mucus and products of decomposition from 
accumulating in the fauces and being drawn into the air passages or being- 
absorbed. For syringing or mopping, solutions containing chlorine, as liq. 
sodae chlorinatae (i to 20), sulphurous acid (1 to 10), boracic acid (1 to 15), 
boroglyceride (saturated solution in glycerine), sanitas (1 to 40), permanga- 
nate of potash (1 to 40), answer very well. The sulphurous acid has the 
disadvantage of frequently containing sulphuric acid, and consequently 
giving rise to smarting if there are many cracks in the lips or excoriations 
about the nose. These can be used every four hours, or more frequently 
according to the severity of the case. Where there is much exudation, or 
sloughing of the tonsils or fauces, some strong caustic solution, as glyeer. 
acidi carbolici, or chinolin 2 to 5 per cent, in alcohol should be employed. 
Nitrate of silver may be applied once or twice a day, having first syringed 
away the mucus ; a saturated solution of salicylic acid in sp. vini rect. is a 
good preparation for painting on. 

There is but little reason to believe that the course of the fever is much 
influenced by internal remedies ; in mild cases a saline such as dilorate of 
potash is useful, giving it only in moderate doses, as 2 to 5 grs. every four 
or six hours ; in larger doses it is apt to be deleterious. In more severe cases 
the treatment must be adapted to the symptoms, stimulants being usually 
required on account of the depression which is so often present. Carbonate 
of ammonia, digitalis, cinchona bark, separately or in combination, are the 
most useful drugs. Diarrhoea, if excessive, must be kept in check by opium 



Treatment of Scarlet Fever 271 

enemata ; if moderate, it had better be left alone. Sleeplessness, headache, 
delirium, are best relieved by an ice bag to the head and full doses of bro- 
mide. We do not believe that biniodide of mercury or other mercurial salt 
is of the slightest use in modifying the severity of the attack. It has failed 
entirely in our hands. 

When the temperature continues high, being 104 to 105 , quinine in 1 to 
3 gr. doses, and repeated packs, so as to get the skin to act, have appeared 
to us the most useful form of treatment. The child should be wrapped up in 
a sheet wrung out of water at 6o° and rolled up in a blanket for an hour. 
This must be repeated if the temperature continues high. Cold spongings 
are also useful. Cold baths require great care on account of the depression 
they are apt to produce ; if used at all, they should consist of the graduated 
bath— that is, the child should be placed in a bath at 90 , the temperature 
being gradually reduced to 6o° by the addition of cold water. Anti-febrin or 
anti pyrin may be used, but their effect is temporary only, and they are apt 
to be accompanied by considerable depression of the heart. These drugs 
are too depressing for malignant cases. The former may be given in 3 to 5 gr. 
doses in sherry or tincture of orange peel, as it is insoluble in water. Oxygen, 
gas has been used with advantage by Cresswell, 1 and we have been well 
pleased with it in some cases in which we have tried it. 

It must, however, be admitted that the treatment of the severer forms of 
scarlet fever is disappointing and often disheartening ; in spite of the most 
devoted nursing, stimulants freely given, antipyretics, liquid nourishment of 
all kinds, antiseptics to the fauces, they go from bad to worse, apparently un- 
influenced by all that has been done for them. On the other hand, it some- 
times happens that cases which at first are most unpromising are apparently 
saved by careful nursing and appropriate treatment, and this fact should 
encourage every effort. In rare instances sloughing fauces will mend, pneu- 
monias clear up, temperatures which have been high for two or even three 
weeks gradually fall, and complete recovery ensue. 

The otitis which so commonly occurs is usually suppurative from the 
first, the tympanic membrane quickly gives way and a free discharge follows. 
Earache should be treated by the instillation of warm camphorated oil to 
which a drop or two of laudanum has been added, and hot fomentations 
may be applied externally. A single drop of glyc. acid, carbolici (B.P.), 
carefully dropped into the ear so as to reach the membrane, usually gives 
relief. If, on examination with the speculum, pus is seen bulging the mem- 
brane, an incision should be made ; but nature usually anticipates the 
surgeon in this matter, and so quickly that the operation is seldom necessary, 
except in those cases where the membrane fails to give way early. The pus 
which forms in scarlet fever appears to penetrate the membrane more quickly 
than the pus formed in non-febrile cases. When a discharge exists, care 
should be taken to keep the ear syringed out, and some antiseptic powder, 
such as iodoform and boracic acid, blown in. The after treatment of chronic 
otitis need not be gone into here. 

The preventive treatment oi post-scarlatinal nephritis consists in the 
greatest care being taken during the second and third weeks to a\ oid cold ami 

1 Practitioner, October [888, 



■2/2 The Specific Fevers 

to keep the skin acting, and to avoid a stimulating diet and any overfeeding. 
1'he child should be sponged daily or bathed, provided there is no risk 
of chill ; the diet should be chiefly fluid, milk, light puddings and sops, and 
the bowels should be acted upon if necessary by laxatives or salines such as 
tartrate of soda or Glauber's salts. On the appearance of albumen a smart 
purge of senna or jalap should be given, and the child dressed in a flannel 
night shirt and placed between the blankets, salines such as citrate of 
potash, liq. ammon. acet., or tartrate of soda, being given. The diet should 
consist entirely of barley water and of milk, or at any rate of fluids. Hot 
packs, a blanket wrung out of hot water being used, or hot vapour baths 
given by means of Allen's apparatus, or warm baths, are always useful in 
acting on the skin and drawing away the blood from the kidneys, and so 
relieving the inflammatory congestion present. The smaller the quantity of 
urine passed the more vigorous should be the packs or baths. Ten grains 
of jaborandi leaves, made into an infusion with hot water, or one-tenth 
of a grain of nitrate of pilocarpine subcutaneously, may be given before 
the packs once or twice a day. Children bear pilocarpine well, but its use 
requires care on account of the cardiac depression it is apt to produce. 
Poultices to the loins should be applied between the packs. Dry cupping 
seems sometimes to be useful and may be tried. If the kidneys fail to act, 
and no urine or only a small quantity is secreted, large enemata of warm 
Avater will sometimes give relief, urine being passed as the enema is being 
expelled. 

During the course of a nephritis the condition of the heart must be 
carefully watched, as also must any tendency to muscular twitchings about 
the face or hands. Any attacks of dyspnoea or evidence of cardiac dilatation 
must be met by the administration of digitalis, two to five drops every two 
liours. Solution of nitro-glycerine in drop doses, inhalation of chloroform, 
•or nitrate of amyl may be tried if convulsions supervene. 

Quarantine. — Six weeks at least— better two months— reckoning from 
the first day of the fever should elapse before a child convalescent from 
scarlet fever can be allowed to rejoin his companions or go to seaside 
lodgings ; and not then if the desquamation is incomplete or there is a dis- 
charge from his nose or ears. In so important a matter as discharging a 
convalescent scarlet fever patient, it is wise to err on the side of caution. 

Measles 

Measles is an acute infectious disorder characterised by coryza and fever 
in the prodromal stage, followed by a peculiar papular eruption on the face 
and body. 

Measles, like whooping cough, prevails in widespread epidemics, though 
its epidemics are of shorter duration ; but sporadic cases are always occur- 
ring in large centres of population. This epidemic prevalence occurs in large 
cities every eighteen months or two years, though the epidemics differ very 
much in their extent and fatality. In these epidemics, when once the 
disease enters a household, or indeed a street or alley, hardly anyone escapes 
who is not protected by a previous attack, the sufferers in nearly all cases 
being young children ; the older children and adults having suffered in pre- 



Measles 273 

vious epidemics. Communities removed from frequent contact with civilisa- 
tion, and where there has been no epidemic prevalent for some time pre- 
viously, invariably suffer severely when the poison of measles is introduced, 
adults being affected as well as children. The most notable instance of this 
in recent times is the epidemic of measles in the Fiji Islands in 1875, which 
raged for four months, 40,000 natives dying out of a population of 1 50,000, ' 
equal to upwards of one in every four of the population, whereas in London 
in 1886, which may be taken as an average year, the deaths from measles 
were five in every 10,000 living (at all ages). The same virulence of an 
epidemic may be seen in a lesser degree in populations, more especially 
among children, in villages or isolated places where there has been no 
epidemic for some time previously. The susceptibility to measles is exceed- 
ingly great in unprotected subjects; thus Biedert, 2 in a small epidemic 
in an isolated village, found only 14 per cent, of the children who were 
unprotected escaped after being exposed to the infection. In the Faroe 
Islands under similar conditions only 4-5 per cent, and 1 per cent, escaped. 3 
The same experience obtains in schools and in the wards of children's 
hospitals, where, if a child has been admitted incubating and remains till 
the rash appears, an epidemic follows, which it is difficult to stop until nearly 
all of the unprotected have been attacked. The epidemics are independent 
of season, and occur in winter as in summer. 

The disease, like most other specific fevers, spreads by contagion, but the 
nature of this has not been satisfactorily determined, though micro-organisms 
have been obtained from the breath and secretions of patients suffering 
from measles by A. Ransome, Braidwood and Vacher, and Canon and 
Pielicke. 4 

We have frequently made cultivations of pus cocci from the blood of 
patients with measles, and such can also be detected by staining a dried drop 
of blood. 

The poison is apparently given off in the breath and other secretions, and 
may be conveyed to a distance by its adhering to the clothes or person of a 
nurse or others coming in contact with the sick. The infection, however, 
appears to be more diffusible or more readily destroyed than the poison of 
smallpox or varicella, as rarely if ever in our experience is it introduced into 
a ward, except by those who were admitted incubating, it being unlike variola 
or varicella poison in this respect, infection in the latter case appearing to be 
brought in by visitors. The infection is known to be given out from the patient 
very early in the attack — that is, from the first appearance of definite symptoms, 
as coryza and fever — but there is good reason to believe that Mr. Yacher is 
right in believing that measles is infectious during the incubative stage, 
as well as during the febrile and eruptive stages. Several instances which 
point strongly to this conclusion have come under our notice. 

The mortality differs enormously according to the circumstances under 
which the attacks develop and also in different epidemics. In healthy 
children among the well-to-do class the mortality is practically////; in the 
tubercular and wasted children to be found in workhouses, hospitals, and 

1 Corncy, quoted by Collie. - fahrduchf&r Kinderheilkunde, vo\ xxiv. p 
3 Madsen, Panunt. " l Brit Med. Join: April 93, 189a. 



274 



The Specific Fevers 



among the lower classes the mortality is enormous, no disease more certainly 
being attended with a fatal result. William Squire places it at 20 to 30 per 
cent, of those attacked in crowded wards. Among dispensary patients the 
mortality generally amounts to 9 or 10 per cent. In our own dispensary, during 
the six years 1 880-1 885, 1,395 cases were treated, with 128 deaths, making a 
mortality of 9 per cent. Of the fatal cases J3 per cent, were under two years 
of age, and 9 per cent, under six months of age. 

Second attacks of true measles are not uncommon. We know one 
family in which one boy has had a severe attack of measles four times, a 
boy and girl three times each, and one girl twice ; all these attacks were 
severe. In many cases where there is said to have been a recurrence of 
measles, one of the attacks has no doubt been rubella. 



SiSig 

ii 



if 



liifiii 



ir'i 




1 nssiiii 

iiiiiii i ■■» 

IIIIIII IIIIIII 




jyfj |y§ 

iriiiillilSliillfiliillliiillliliii 

iIliiii§|jiiiili8]i(IliijiSlES| 



Fig. 42. — Temperature Charts of cases of Measles. *, rash present. 

Infants are occasionally born with the rash of measles on them. 1 
Incubation. — When inoculated this appears to be seven or eight days, 
when contracted in the usual way it is mostly ten to twelve days, the rash 
appearing on the fourteenth or sixteenth day. 

Symptoms. Prodrojnal Stage. — The early symptoms are those of a 
feverish cold. The child sneezes, waters at the eyes, there is catarrh of the 
.nasal membrane, with usually a hard hacking or perhaps croupy cough. 
Sometimes the symptoms are those of a catarrhal laryngitis or bronchitis. 
On everting the eyelids the palpebral conjunctiva is seen to be red and con- 
gested, and the fauces and tonsils are hyperaemic with excessive secretion. 
The child is feverish, often acutely ill, the temperature rising in the evening 
a degree or two and usually falling again in the morning ; this continues, 
1 See Helm, Medical Chronicle, May 1890, and Brit. Med. Jour. vol. i. p. 602, 1890. 



Measles 



275 



though becoming increasingly marked, till the rash is fully developed. 
Sometimes there is a marked remission on the second or third day (see 
fig. 43). Often a blotchy redness about the face precedes the papular 
eruption. Earache occasionally occurs. 

Eruptive Stage. — The characteristic eruption usually makes its appear- 
ance at the end of the fourth day, on the forehead, face, neck, and 
fauces. The child's appearance at this time is so characteristic that in 
well-marked cases a glance is sufficient to establish the diagnosis. The 
flace is flushed, the eyes red and watering, there is a short cough, the fore- 
head, nose, and cheeks are covered with crops of dusky red papules, sur- 
rounded by a zone of erythema which contrasts with the normal skin 





HPIGHIH ii 

SMSMSftS S 




fas» 

.¥jSbs;b|;] «j 



■ ■■ ■IIWHIM HIH 

scarce as: 
ssasusiKsss 



iiiii iiiiiiilliiiiiii 



Fis 



43. — Temperature Chart of a case of Measles, complicated with Broncho-pneumonia. 
* rash. 



between the groups. The papules can be distinctly seen and felt, and 
though not 'shotty' to the touch, yet they have often a distinct feeling ot 
hardness. The rash on the face is usually both patchy and discrete, the 
patches being made up of confluent papules, the latter of small groups or 
single papules arranged at times in small crescents or semicircles. In 
the course of a day or two the rest of the body is more or less covered with 
the rash ; it is apt to be confluent with much erythematous redness on the 
dependent surfaces, the extensor surfaces of the arm and thigh, the back 
and buttocks, and more discrete or spotty on the chest and rest of the both'. 
By the fifth or sixth day the eruption is at its height, and, beginning 
to fade first on the face and later on the body and limbs, is followed. 



276 The Specific Fevers 

especially on the face, by a fine desquamation. By the seventh or eighth the 
rash has completely disappeared, leaving at most only an indefinite mot- 
tling or staining over the body. The temperature, which has probably 
reached 103 to 105 by the sixth day, quickly falls to normal or thereabouts^ 
and the headache and discomfort are gone and the child seems greatly 
relieved. In severe cases in weakly children the crisis maybe accompanied 
by much exhaustion, but this rarely happens. The temperature remaining high 
indicates some complication such as bronchitis or pneumonia (see fig. 43). 

Mild or ill-defined Measles. — Very often all the symptoms are milder 
than those just described, but at the same time are perfectly characteristic. 
On the other hand, the attack may be so slight as to be recognised with diffi- 
culty. There may be almost an entire absence of symptoms in the prodromal 
stage, or a temperature only reaching ioo° or ioi c , the coryza and catarrh 
being insignificant, while the rash is represented by ill-defined and character- 
less papules about the neck, back of the hands, and thighs. In other cases 
probably the catarrh and laryngeal symptoms are well marked, the child, 
evidently suffering from a laryngitis ; this is followed by an indefinite mot- 
tling about the neck and hands as the laryngeal symptoms abate. 

Severe and Complicated Measles. — Epidemics of measles differ greatly 
in the severity of the individual attacks. Most of these fatal attacks are 
characterised by high fever, dry brown tongue, delirium, and convulsions, due 
to an intense hyperaemia of the internal organs, more especially the lungs 
and brain. The heart's action is depressed, the rash ill defined, the skin 
dusky, and in some cases markedly petechial. In such cases death may take 
place on the third or fourth day, or improvement may commence at the end 
of a week. In the majority of cases measles threatens life through the 
tendency to inflammation of the lungs. The lung symptoms may be pro- 
minent from the first, or the presence of pneumonia may delay convalescence 
or supervene when the acute symptoms have passed away. In the former 
case the symptoms are those of acute broncho-pneumonia, the temperature 
continues high, perhaps 105 or 106 , there is marked dyspnoea, sibilant sounds 
are heard over the whole chest, the air does not enter the bases freely ; the 
rash is scanty, perhaps only an ill-defined mottling ; delirium followed by 
coma comes on ; the eyelids become glued together with thick semi-purulent 
secretion, sordes appear on the mouth, the tongue is brown and dry, and 
unless improvement takes place the child sinks. 

Catarrhal or Membranous Laryngitis is not uncommon in the pre- 
emptive stage, or as the eruption is receding. Tracheotomy may be required 
if the obstruction to respiration becomes sufficient to threaten life, but it 
must be borne in mind that an amelioration of symptoms generally takes 
place when the rash appears. In those cases attended with membranous 
exudation the laryngitis generally follows rather than precedes the eruption. 
Ophthalmia frequently occurs in anaemic and unhealthy children ; corneitis 
and corneal ulcers may also be met with. Glandular enlargements 
may develop, the deep cervical gland being especially involved, as in scarlet 
fever ; abscesses are not common, otitis is very common during con- 
valescence, suppuration taking place in the middle ear and the membrane 
becoming perforated. Diarrhoea is not an uncommon complication or 
sequela, especially during the hot weather, though by no means exclusively 



Measles 277 

so ; it is apt to become dysenteric in character, mucus, blood, and hard lumpy 
faeces being passed, with prolapse of the bowel. 

The health often remains impaired for a considerable time after an attack 
-of measles ; it is during this stage that Acute Tuberculosis and Cancrum 
oris may arise. The tuberculosis very frequently appears to take its rise 
from enlarged and cheesy bronchial glands. 

Diagnosis. — The disease most likely to be mistaken for measles is rubella, 
the latter disease closely resembling mild measles. (See Rubella.) A 
measly rash is sometimes present in cases of septicaemia, where there is 
suppuration as in empyema. 

It is possible to confound measles with smallpox, though this difficulty is 
more likely to arise in the case of adults than children. According to Collie 
there are two kinds of smallpox which it is possible to confound with measles, 
viz. the commencement of a confluent case and the commencement of a haemor- 
rhagic case. The papules in smallpox are much harder and more shotty, 
and, moreover, in a confluent case, the headache, lumbar pain, and general 
symptoms would be more severe. Haemorrhagic measles is very rare, and, 
according to the same author, would be difficult to diagnose from ' black 
smallpox ; ' the quantity and quality of the vaccination marks should be 
taken into account. 

Morbid Anatomy. — -There is not much to be said under this head, inas- 
much as there are no post-mortem appearances characteristic of measles, 
the principal lesion found being catarrhal pneumonia ; the whole of the 
internal organs are gorged with blood, and minute haemorrhages are present 
on their surfaces. The mucous membrane of the bronchi is intensely con- 
gested, the surface of the pleura roughened and perhaps covered with lymph, 
one or both bases being solid from catarrhal pneumonia ; in such case the 
pneumonia resembles that found in septicaemia. In some instances croupous 
pneumonia involving a lobe or portion of a lobe may be present, or there 
may be patches of croupous pneumonia. At other times there is intense 
bronchitis, with patches of catarrhal pneumonia and emphysema. In all 
cases of pneumonia following measles which we have examined micro- 
scopically we have found fibrinous exudation in the air vesicles, in spite of 
the pneumonia being apparently of the catarrhal variety. 

The following post-mortem record taken from one of our note books 
illustrates a malignant case : — 

Measles, malignant case; death. — Child of eleven months; death on fourth day. 
On removing lungs it is noted that the upper lobes are emphysematous on their surfaces ; 
in the lower lobes emphysema alternates with collapse ; on section there is intense 
injection of the trachea and bronchi, yellow mucus exudes from the minute bronchi ; the 
lungs are intensely congested, there are patches of broncho-pneumonia in the lower lobes. 

Treatment. — No very active treatment is needed during an attack ot 
ordinary severity, but much may be done to promote the patient's comfort and 
to prevent any complications. He should, of course, be confined to bed as 
soon as measles is suspected, the temperature of the room being maintained 
at 65 F., and if the cough is hard and irritating a steam kettle should be 
called into requisition to keep the atmosphere moist. The diet should con- 
sist of milk diluted with barley water or seltzer ; in mild cases sops or light 



278 The Specific Fevers 

puddings may be allowed. Demulcent drinks, such as barley water, lemonade, 
black currant or tamarind drinks or jellies, are useful in allaying the irritating 
cough. Frequently spongings with warm water containing a weak solution 
of tar or ' sanitas : relieve the itching and help to bring out the rash. During 
the pre-emptive stage, when there are high fever, restlessness, cough, and 
frequent pulse, small doses of tr. aconiti, one or two drops every two hours 
— carefully watching the effect, especially after five or six doses have been 
given — will be usually attended with relief. Jelly containing codeia or small 
doses of Dover's powder may be given to relieve the cough. Great care 
should be exercised during convalescence to prevent catching cold, especially 
in those who are liable to bronchial catarrh, as the bronchial mucous mem- 
brane remains for some time in an irritable condition, and exposure to cold is 
exceedingly likely to give rise to bronchitis or diarrhoea. 

In cases of greater severity, especially those in small children which are 
accompanied by a scanty rash, congestion of the internal organs, high tem- 
perature, and broncho-pneumonia, active treatment is required. It is neces- 
sary to get the skin to act efficiently and thus relieve the congested internal 
organs ; to this end tepid sponging, hot packs, or mustard baths may be em- 
ployed. For children under two years of age the mustard bath is the most 
suitable ; the child being placed for three minutes in a bath of ioo° F., one 
table-spoonful of mustard to the gallon of water being about the proper 
strength. The child must be quickly dried and put between blankets ; the 
bath may be repeated in a couple of hours if necessary. The stimulating 
effect of the bath upon the skin is often of great service. Linseed poultices 
to the chest are to be avoided in the case of young children, unless the atten- 
dants are trained nurses ; hot fomentations or bran poultices are preferable in 
dispensary practice and in the hands of the unskilled, as being less heavy. 

In older children the hot pack is to be preferred to baths. In the early 
stages small doses of antimony, pot. ant. tart. T ^o _ io of a grain, with some 
tartarated soda or citrate of ammonia, should be given every three or four 
hours, but omitted if there is nausea. Aconite may be useful, but it must be 
carefully watched, on account of the depression it is apt to produce if pushed 
too far. Alcohol in the form of whisky or brandy should be given if the 
pulse is small and rapid and the tongue diy and brown. If the cough be- 
comes loose and there is excessive secretion from the bronchi, ammonia, 
digitalis, and alcohol in combination should be given. The eyes, nose, and 
mouth in severe cases require attention ; they should be bathed or mopped 
out with warm water ; if there are any aphthous patches in the mouth some 
borax in dilute glycerine should be applied. Otitis and glandular inflamma- 
tion may require attention. During convalescence no medicine answers 
better than nitric acid and bark. 

Quara7iti?ie. — How long should quarantine be maintained in a case of 
measles ? This is not an easy question to answer, though it is certain that 
the infection is not given off from the patient for so long a period as is the 
case in scarlet fever. In uncomplicated cases hot baths may be given as the 
rash begins to disappear ; they are useful to cleanse the skin and render the 
patient more comfortable. It is well for the patient to keep his bed for ten 
days and his room for three weeks ; then, if he is quite well in every respect, 
there can be little danger in his mixing with his fellows. When a case of 



Rubella 279 

measles occurs in a house, it is necessary for the other children who have 
not had it to stop going to school or mixing with other children, as it is 
probable they will have contracted the disease ; and as measles is infec- 
tious in its early stages— if not during the incubation period — they may 
readily be the means of giving it to others. For the same reason it is unwise 
to send them away from home, though care should be taken that they do not 
come in contact with the patient at home. The bedding should be stoved and 
the room occupied by the patient disinfected at the conclusion of the illness. 

Rotheln or Rubella 

Rubella 1 is an infectious fever closely resembling but distinct from measles ; 
it is for the most part a milder disorder than measles, and does not protect 
from it. In some epidemics it closely resembles mild scarlet fever. 

Etiology. — The resemblance between these two diseases is unquestionably 
a close one, and there is little doubt that not infrequently epidemics of 
rubella — or at any rate sporadic cases — are mistaken for measles. It has, 
however, been clearly shown by those who have had the opportunity of 
watching successive epidemics of infectious diseases in schools and asylums, 
where the same individuals have been attacked, that rubella does not 
protect from either measles or scarlet fever, nor do attacks of the two latter 
afford any immunity from attacks of rubella. The resemblance, and yet the 
difference, between the two diseases is well put by Dr. West when he says 
* they resemble each other somewhat as varicella and variola — alike, but not 
the same — not twin sisters indeed, but half-sisters at any rate.' That they 
should be confounded in practice is not surprising, especially when we re- 
member that measles is sometimes an extremely slight disease and the rash 
by no means characteristic. In mild attacks of measles the coryzais usually 
slight or absent, and the rash little else than ill-defined mottling. 

Rubella occurs in epidemics, sometimes being prevalent and widespread, 
as it was in this country during 1S80 ; at other times sporadic cases crop up 
and there appears but little tendency for the disease to spread. As a result, 
rubella has earned a different character as regards contagiousness from 
different writers who have observed it, some maintaining that its contagious- 
ness is almost ;z2*/, and others that it is extremely contagious. The truth is 
that susceptibility to its influence seems to vary strangely at different times 
and in different places in a way which it is difficult to account for. Thus in 
one locality there may be an epidemic prevalent ; an individual goes to 
another while incubating, he suffers from an ordinary attack and the disease 
does not spread, though he comes in contact with many individuals. There 
is little doubt, however, that rubella has been confounded with some of the non- 
specific, non-contagious forms of roseola or rose rash. Age does not seem 
greatly to influence predisposition : infants, children, and adults suffering alike : 
indeed, in some epidemics adults suiter more in proportion to their numbers. 
Thus in an epidemic in the Children's Hospital observed by Dr. Hutton and 
ourselves, out of twenty-seven cases, eight were those oi lady probationers or 
'sisters,' and nineteen of children ; so that the adults suffered far more 

1 We adopt the term rubella as first suggested, we believe, in- W. Squire. ' Epidemic 
roseola,' which has been proposed, introduces the ambiguous term of ' ros< 



2 So T/ie Specific Fevers 

largely in proportion to their numbers, though there can be no doubt that the 
nurses came in contact with those suffering trom the disease much more than 
the children. Considering how much rarer a disease rubella is than measles, 
it would appear that a smaller number of individuals who are unprotected by 
a previous attack are susceptible to its influence. 

The relationship of rubella to measles and scarlet fever is an interesting 
question, and while very few believe it to be a hybrid disease, the attack 
resulting from the reception by the patient of both scarlatinal and measles 
poisons, yet, considering the close resemblance which it bears to measles, 
there is nothing inherently improbable in the idea that the resemblance is 
something more than coincidental, that the poisons may have been derived 
from one another or from the same stock at some distant epoch, and have 
become modified by being cultivated under different conditions. It is inte- 
resting to note that some observers assert that the character of an epidemic 
becomes modified in the direction of either measles or scarlet fever if either 
of these is prevailing at the same time. 

It is a curious fact that there are epidemics of rubella, in which the rash 
closely resembles scarlet fever and not measles, as is generally the case. 
Whether the two forms are distinct diseases or only varieties of the same 
disease, it is impossible to say. We cannot say whether the measles variety 
protects from the scarlatinal variety. 

Incubation. — There has been some uncertainty about the length of the 
incubation period. The common period is from two to three weeks, as 
observed both by W. Squire and Lewis Smith. In three cases coming 
under our own observation the time appeared to be sixteen, seventeen, and 
eighteen days respectively. 

Premonitory Stage. — In children, as a rule, no prodromal symptoms are 
observed, the rash being the first thing to be noticed. In adults who are 
able to describe their feelings, complaint is made of weariness, headache, and 
backache for twenty-four hours before the appearance of the rash. There 
may be vomiting, coryza, slight sore throat, or a tingling sensation of the 
skin of the face. Another noteworthy symptom sometimes present is the 
enlargement of the superficial lymphatic glands situated along the posterior 
edge of the sterno-mastoid, or the submaxillary and occipital glands are tender 
as well as slightly enlarged, and give rise to a certain amount of stiffness 
of the neck. On the other hand, it is by no means uncommon even in adults 
that the discovery of a rash is the first thing to call attention to the attack. 

Prodromal Stage. XVEeasles variety. — The rash usually appears first on 
the face, and consists of indistinct, ill-defined papules, forming irregular 
patches of a rose-red colour, which shade away into the colour of the skin ; 
there may be simply erythematous blotches. The patches of confluent 
papules vary much in size and shape, many perhaps consisting of only a few 
papules grouped together ; sometimes, on the contrary, the whole face is of 
a red colour. The rash is usually also abundant on the neck, chest, back, 
buttocks, and flexor surfaces of the arms and thighs ; in these situations it 
is usually less confluent and patchy than on the face, the rash consisting of 
groups of papules or of single papules. Occasionally the confluence of the 
papules and the erythema which surrounds them give rise to the suspicion 



Rubella 281 

of scarlet fever, especially lo that form in which the rash is patchy on the 
limbs, but the rash of rubella always consists of papules, and is not diffuse 
or punctated as is the rash of scarlet fever. Rubella rashes undoubtedly 
vary considerably, especially in the confluence of the papules ; as a rule, 
the colour is of a rose-red when it first comes out, being of a brighter colour 
than measles ; the papules do not so constantly arrange themselves in 
crescents, and they are less distinct than the measles papules. The rash is 
usually most intense on the second day, but remains visible for three or 
four days ; by the end of this time it has mostly faded, often leaving more 
or less staining of the skin and a light branny desquamation. The rash 
frequently gives rise to much itching. Sometimes the axillary and inguinal 
glands become enlarged. 

The course of the attack may be feverless, though usually there is a slight 
rise of temperature, the highest being on the second day, 99 to ioo°; in rare 
cases it reaches 102 or 103 . The temperature becomes normal as the rash 
disappears. 

Hypersemia of the conjunctiva and fauces exists in many cases, but it is 
rarely as marked a feature of the attack as it is in measles. Sometimes a 
dryness and soreness of the throat in swallowing is complained of, with more 
or less catarrhal tonsillitis. 

While such may be taken as a typical attack, it must be acknowledged 
that the attacks of this exanthem vary greatly in intensity, and the rash may 
be too ill defined to admit of a positive diagnosis. In some rare cases, such 
as those described by Dr. Cheadle, the course of the disease is that of a serious 
illness, with marked implication of the larynx and bronchi, the cough being 
incessant and crouplike. In two of these broncho-pneumonia supervened, 
in several others earache was a prominent symptom. On the other hand, 
cases may occur of the mildest form, so wanting in character both as regards 
rash and coryza, that they may be looked upon as of a doubtful nature and 
perhaps forgotten, and only when they are succeeded by more typical cases 
does their character become clear. 

Scarlatinal variety. — Some years ago we were much puzzled by finding 
that a number of what were apparently mild cases of scarlet fever, when 
admitted to our fever ward developed scarlet fever a few days after their 
admission. Shortly after we noted a number of patients coming to the out- 
patient department with diffuse red rashes, but who were hardly ill at all, 
but had been brought on account of the rash. It soon became apparent 
that there was an epidemic of a disease closely resembling scarlet fever yet 
distinct from it, inasmuch as it left the patient still susceptible to an attack 
of scarlet fever. This epidemic was no doubt one of the scarlatinal variety 
of rubella. In many of the cases there was a history of vomiting as an 
initial symptom, complaint of sore throat, slight fever, and a very well-marked 
rash, while the child hardly felt ill at all. The rash was usually copious 
and could not be distinguished from scarlet fever rashes, but was more of a 
rose tint and less distinctly punctiform in character that is. there was .1 
uniform redness, without the red points, which correspond with the hair 
follicles, being well marked. Still, we must admit that the rash seen in 
these cases was indistinguishable from some undoubted scarlet fever rashes. 



282 TJie Specific Fevers 

When once such an epidemic is known to prevail the diagnosis ceases to be 
difficult. The fever, malaise, and sore throat are slight, while the rash is copi- 
ous. In scarlet fever with a copious rash the fever is usually high, the tonsils 
are angry and swollen, and the child is evidently ill. Mild cases would not be 
likely to occur one after another ; some would be certain to be sharp and 
typical. Desquamation follows the red rash of rubella, but it is rarely as well 
marked as in typical cases of scarlet fever, where the rash has been copious 
and the fever sharp. Some authors lay great stress on the enlargement of 
the lymphatic glands behind the sterno-mastoid, axilla, and inguinal region. 
This is no doubt true, but they are not universally enlarged ; we have 
certainly seen cases of both varieties of rubella without any lymphatic 
enlargement. In some cases and in some epidemics the rash is more 
patchy than the rash described, but we have not seen many such. It must 
be borne in mind that the scarlatinal variety of rubella is a comparatively 
rare disease, while scarlet fever is a very common one, and that an isolated 
case of fever with sore throat and a diffuse red rash is far more likely to be 
scarlet fever than rubella, however mild and uncomplicated it may prove to 
be. To find that a child we have declared to be suffering from ' German 
measles ' has acute nephritis is, to say the least of it, an unpleasant dis- 
covery. 

Rose rashes, diffuse and patchy, may make their appearance after the 
ingestion of some improper food, or in hot summer weather. There is usually 
an absence of both sore throat and fever. The possibility of a red rash 
being due to belladonna must not be forgotten. 

Complications and Sequelce. — -There are usually none ; in the more severe 
cases catarrhal disorders, such as coryza, tonsillitis, and broncho-pneumonia 
may complicate and succeed the attack. The prognosis is favourable ; the 
disease is probably never fatal in healthy children ; in epidemics in hospitals, 
where it attacks children already suffering from and much reduced by 
pulmonary affections, it has appeared to be the immediate cause of a fatal 
result. Even in healthy children the health may remain below par for 
some time afterwards. 

Diagnosis. — Rubella may at times be mistaken for some of the anomalous 
erythematous or roseolous rashes from which children suffer from various 
causes, especially indigestible food, but there is usually no fever. In single 
cases diagnosis may be difficult, but the fact that rubella prevails in epidemics 
often assists in making a diagnosis. The diagnosis between measles and 
rubella in an individual case is at times impossible ; often it is difficult, 
inasmuch as it must be admitted that there is no one characteristic symptom 
of rubella, and moreover the rash differs in different cases. The differences 
between typical cases of rubella, measles, and scarlet fever are shown in 
the table opposite. 

Treatment. — Every case of rubella and every suspicious case should be 
carefully isolated, and confined to one room, if not to bed. The diet should 
consist largely of fluids and slops. A simple saline such as citrate of potash 
may be given, and other symptoms must be treated as they arise. 

Quaraiitine. — The patient should be isolated for at least three weeks ; 
better if four weeks elapse before he is allowed to rejoin his companions. 



Diphtheria 



283 



Rubella 



Incubation. 
Premonitory fev. 
Prodromal sym- 
ptoms. 



Tonsillitis. 



Rash. 



Desquamation. 



Temperature. 



14 to 21 days. 

1 day. 

Often none. Sometimes 
enlarged glands, 
weariness and slight 
coryza. 

Slight tonsillitis. 

Appears on the first or 
second day. Con- 
sists of indistinct 
papules of a rose-red 
colour confluent on 
the face, usually dis- 
crete on the limbs, 
buttocks, and thighs. 
Often fades from the 
face before it is fully 
developed elsewhere. 
Often much itching. 

In the scarlatinal va- 
riety the rash closely 
resembles scarlet 
fever. It is rose- 
red, diffuse, less 
markedly puncti- 
form than typical 
scarlet fever. 

Desquamation absent 
or only very fine 
branny scales. 

Often normal through- 
out, rarely above 
ioo° F. 



Measles 



Scarlet Fever 



8 to 12 days. 2 to 5 days. 
3 to 4 days. 1 day. 
Sneezing, coryza, Vomiting, head- 
headache, cough. ache, sore threat. 



Usually none. 

Appears on the 
fourth or fifth day. 
Consists of conflu- 
ent papules of a 
dusky red colour 
on the face, and 
groups of papules 
often in a crescen- 
tic form on the 
trunk and limbs. 



Desquamation ab- 
sent or only in fine 
scales. 

Fever always pre- 
sent, sometimes 
high, reaches its 
maximum when 
the rash is fully 
out, then falls. 



Tonsillitis well 
marked. 

A diffuse punctiform 
red rash comes 
over neck, trunk, 
and limbs — may 
be patches on the 
extremities. 



Desquamation usu- 
ally free. 

Fever always pre- 
sent, mostly high, 
disappears as the 
rash fades. 



, Diphtheria 

Diphtheria is an infectious disorder which is characterised by the for- 
mation of a fibrinous exudation on mucous surfaces, caused by the develop- 
ment of a peculiar bacillus ; it is usually accompanied by anaemia and 
albuminuria, and frequently followed by paresis of various muscles. At the 
very threshold of the subject it may be as well to attempt to clear the ground 
by asking— Are we to consider all fibrinous exudations which have the 
characters of a ' false membrane ' as evidence of the presence of diphtheria ? 
Is diphtheria always accompanied by a v false membrane'? Both these 
questions must be answered in the negative. Recent observations clearly 
show that other micro-organisms besides the D-bacillus are capable o\ pro- 
ducing fibrinous exudations on the fauces, and, moreover, the D-bacillus has 
been demonstrated in the secretions taken from what weie apparently non- 
membranous sore throats. Still, we must admit that membranous exudations 
are usually diphtheritic, and that diphtheria is rarely present in the absence 
of ' false membrane.' 



284 The Specific Fevers 

That diphtheria is a highly contagious disorder is made certain by very 
definite evidence ; it is a matter of common experience that the disease 
passes from patient to nurse, from one patient to another in the wards of a 
hospital, and from a sick child to its playmates or parents in private houses. 
It is certain also that the infection can be conveyed from the sick to the 
healthy by means of a third person, the infective particles travelling on the 
clothes or on the hands of the latter. Direct inoculation has taken place 
accidentally by means of small pieces of membrane or the secretions enter- 
ing the mouth, as in sucking a tracheotomy wound ; false membrane has 
formed within twenty-four hours of an operation at the seat of the wound. 
There is little doubt also that the disease has been transferred from animals 
to man through direct contact or by means of milk from cows suffering from 
the disease. The D-bacillus may retain its vitality for many months out- 
side the body, and may be carried any distance in clothes, bed linen, or on 
surgical instruments. It is possible that the D-bacillus may grow and de- 
velop in sewage, in cesspools, and drains, and re-enter the body by the 
inhalation of sewer gas. It is a popular notion that there is a close con- 
nection between diphtheria and sewer gas, and sanitary faults in houses are 
frequently credited with being the cause of outbreaks of diphtheria ; and it 
is quite possible that sewer gas may give rise to a non-specific sore throat 
which may form a suitable soil for the development of the D-bacillus. 

Diphtheria occurs in epidemics, but it is also endemic in some cities and 
rural districts. It is constantly present in such cities as Berlin, Paris, and 
New York, and in some rural districts in this country. In its distribution 
and in the varying character of its epidemics it is one of the most mysterious 
•diseases with which we are acquainted, and there is much about it which 
requires continued investigation. In this country until recently it has been 
more common in the rural than in the urban districts, though it appears at 
the present time to be more common now in our large towns than formerly. 
It is especially prevalent in the south-eastern and eastern rural districts, 
while some- others appear to escape almost entirely. It makes its appear- 
ance at times in isolated farmhouses, or villages remote from other habi- 
tations, and this 'circumstance has suggested the idea that possibly the 
infective particles have been conveyed thither by means of the wind (Airy). 
It has occurred in Central Africa far away from any source of infection. 
But in connection with these singular cases we must remember that the 
D-bacillus retains its vitality for many months under suitable conditions, 
and may be conveyed any distance on clothes or other articles, and thus 
infect persons long distances away from the original source of the infection. 

No age is exempt from its attacks, but children between the ages of two 
and eight years are most often attacked, and children of these ages more 
readily succumb than do older children. The disposition to diphtheria 
seems to run in families, members of the same family being attacked in 
■quick succession or at variable intervals. 

The parts which are most often attacked are the fauces, nasal mucous 
membrane, larynx and trachea, glans penis and vulva ; or, may be, some wound 
•or eczematous skin. The bacillus enters the mouth in either air or food, 
and if conditions are favourable for its development the growth of the 
bacillus commences, and membrane forms on the tonsils and soft palate. 



Diphtheria 285 

In what these favourable conditions consist it is difficult to say. Cer- 
tainly a slight sore throat or laryngeal catarrh often precedes an attack 
of diphtheria, and it is very probable that any injury fo the epithelium or a 
catarrhal state may afford a suitable soil for the development of the bacillus. 
We have known instances in which nasal diphtheria has supervened in a 
case of chronic ozaena, while other children exposed to infection at the 
same time were not attacked. The fatality of different epidemics varies 
strangely ; sometimes whole families are swept away, as in the epidemic de- 
scribed by Trousseau in Sologne, where in one farm, where the residents 
numbered eighteen, only two, the father and a servant girl, survived. The 
infection seems to vary in intensity, at times and under certain conditions 
becoming attenuated, at other times resuming its virulency. 

Morbid Anatomy and Pathology.— The membranous exudation which is 
present in diphtheria is of a whitish-grey colour, and when first formed is 
firmly adherent to the tissues beneath it. It is in some cases rather yellowish 
than white; in malignant cases it is frequently brown from being stained 
by broken-down blood. In a few days more or less the membrane becomes 
loosened from its attachment and can be removed by means of a brush ; if 
forcibly removed it leaves a raw surface, which quickly becomes again 
covered with membrane. Speaking generally, membrane adheres more 
firmly and is less easily detached from the mucous membrane of the tonsils 
and soft palate than from the larynx and trachea. If a thin section of a 
piece of membrane adhering to the soft palate be stained with methyl- 
blue, and examined with a moderately high power, it will be seen that the 
membrane consists of a fine network of fibrin with epithelial cells and 
leucocytes in the meshes ; beneath the membrane the papillae and connective 
tissue of the deeper layers of the mucous membrane will be seen to be in- 
filtrated with leucocytes. On the surface of the fibrinous exudation many 
cocci of various kinds are visible, such as are commonly to be seen in the 
mouth or alimentary canal. Loeffler's D-bacilli are to be seen usually in 
little balls or masses embedded in the. superficial layers of the false mem- 
brane ; in some cases they may be seen in the deeper part of the membrane 
or beneath it. Unlike the anthrax bacillus, the D-bacillus remains local T 
and does not penetrate into the tissues or enter the blood. The D-bacillus 
is a non-motile little rod about the length of the tubercle bacillus, but- 
thicker, so that when several are joined together they look at first sight not 
unlike streptococci. When fully developed the ends of the bacilli are 
darker and thicker than their central portions, sometimes only one end is 
enlarged. Two are often joined together, but not infrequently more. They 
vary considerably in shape and size, according to their age and the conditions 
under which they have grown. The chemistry of the membranes and the 
poisons formed in the exudations and in the blood have been studied by 
Roux and Yersin, and more recently by Sidney Martin (Lancet, March 26, 
1892). The latter observer has established the fact that during the growth 
of the bacilli a ferment is formed which is capable of digesting proteids, 
certain albumoses being formed which act as virulent poisons on the system. 
These albumoses are formed locally and are then absorbed into the blood ; 
but it appears the ferment is also present in the blood, and by its action on 
the proteids of the blood and tissues albumoses maybe formed in the spleen 



286 The Specific Fevers 

and other organs. Similar poisons are formed when the bacilli are cul- 
tivated in blood serum or in gelatine. Roux and Yersin have shown that if 
the nutrient fluids in which the bacilli have grown are, after the bacilli have 
"been separated by nitration, injected subcutaneously into guinea pigs, death 
takes place with symptoms of toxaemia in twenty-four hours. If small doses 
were employed and injected into rabbits, and a fatal result did not take 
place, a paralysis was often left. The poison appears to give rise to de- 
generation of the tissues ; there are changes in the liver cells, the muscular 
fibres of the heart and other organs, and the smaller motor and sensory 
nerves. In the peripheral nerves the white substance of Schwann undergoes 
degeneration, and in places disappears ; the axis cylinder is also affected, 
hut in less degree. It is this peripheral degeneration of the nerves which is 
the cause of the paralysis so often noted after an attack of diphtheria. The 
blood is profoundly altered and its coagulability interfered with ; hence 
the haemorrhages and purpuric condition seen in malignant cases of 
diphtheria. The cause of the albuminuria is uncertain ; it may be caused 
hy the altered state of the blood, or be due to the fatty degeneration which 
the renal epithelium undergoes ; the amount of albumen present is in most 
cases a correct index of the severity of the attack. 

From the above facts it would appear that the D-bacillus is the 
primary infective agent, and that during its growth it gives rise to the 
fibrinous exudation ; at the same time a ferment is formed resembling pep- 
sine which is capable of digesting proteids. This proteid digestion goes on 
both in the membranous exudation and also in the blood, albumoses being 
formed, which play the part of virulent poisons, giving rise to rapid tissue 
degeneration and serious changes in the blood. The relation between the 
diphtheria of man and that of the domestic animals is interesting and im- 
portant. Some of our domestic animals appear to suffer not infrequently 
from diphtheria, and may be the means of giving rise to epidemics of human 
diphtheria. The observations of Klein 1 have shown that diphtheria may be 
communicated to cows by subcutaneous injections of cultivations of bacilli 
from the membrane taken from cases of human diphtheria. A soft tender 
swelling forms at the seat of the injection, and in some cases at least a 
number of pimples appear on the udders, which pass through the stages of 
pustules and ulcers. The cows suffer more or less from fever, and an exten- 
sive loss of hair takes place. During the eruptive stage the milk of some 
of the cows was found to contain numerous diphtheria bacilli. In at least 
two epidemics of diphtheria in which the milk coming from a certain dairy 
was suspected of being the cause, it was found on examination of the cows 
that they were suffering from an eruptive disorder on their udders similar to 
that produced in those cows which had been inoculated. Diphtheria has 
been produced by Klein in cats by feeding them with cultures of the D-bacillus 
in milk, and epidemics of diphtheria have been observed in cats. Guinea 
pigs are the most susceptible of all the domestic animals. Fowls suffer from 
membranous croup which closely resembles, if it is not identical with, human 
diphtheria. 

Pharyngeal Diphtheria. — The tonsils, uvula, and pillars of the fauces 
are the favourite sites for the false membrane in diphtheria, and in by far 
1 Twentieth annual report of the Local Government Board. 



Diphtheria 287 

the greater number of cases occurring in practice these parts are affected in 
the first instance. The attack, unlike scarlet fever, usually begins insidiously. 
The friends notice that the child is ailing, it does not care for its toys, it is 
peevish and fretful, and towards evening is feverish. Perhaps there is some 
glandular enlargement at the angles of the jaw, or a discharge from the 
nose, or the child is heavy and drowsy. In older children there is usually 
some complaint of sore throat or difficulty in swallowing ; the child feels cold 
and shivery, and sits over the fire trying to keep itself warm, An examination 
of the fauces, if made within a few hours of the first symptoms, may show 
nothing very distinctive ; there may be some swelling and excessive redness, 
with some whitish or yellowish exudation in points or patches, but it may be 
quite impossible to decide whether the case is one of diphtheria, scarlet 
fever, or other form of tonsillitis. Usually, however, within twenty-four hours 
of the commencement of the illness, patches of membranous exudation may 
be seen on the inner surfaces of the tonsils or soft palate ; these are whitish 
or grey and opaque, adhering firmly to the surface so that they cannot be 
removed by brushing. If removed by forceps, a raw bleeding surface is left ; 
a piece of membrane when removed is seen to be tough and firm, differing 
from the soft cheesy material which is present in scarlet fever or tonsillitis. 
The temperature is rarely high, being mostly 101 to 103 F. ; the evening 
temperature being, as a rule, a degree or two higher than the morning tem- 
perature. In a day or two, if not from the first, membranous exudation may 
be seen on the uvula or the pillars of the fauces, though the tonsils may be 
from first to last the only part affected. The nasal mucous membrane is apt 
to join in the inflammatory process ; a semi-purulent, often bloody discharge 
makes its appearance at the nostrils ; the child makes a snoring noise when 
asleep, on account of the obstruction caused by the swelling of the mucous 
membrane and the excessive secretion. An examination of the urine during 
the first day or two may be negative as far as albumen is concerned, but if 
a daily examination be made, in the great majority of cases albumen vary- 
ing in amount from a trace to one-half will be found. During the next few 
days* fresh patches of membrane make their appearance on the fauces, the 
older ones becoming loosened, then detached, by the process of sloughing 
which goes on. In the meantime the glandular enlargement and tender- 
ness become more marked, and the neck is stiff and all movements are 
painful. The patient becomes weak, anaemic, and easily exhausted ; there is 
often marked fcetor of the breath. In favourable cases, after the first few 
days or a week no new membrane forms, while the old patches disappear, the 
swelling of the glands and tonsils becomes less, and the temperature gradually 
falls. The albumen also gradually diminishes in quantity and finally dis- 
appears. The child remains weak for a long time, convalescence being only 
slowly established. On the other hand, in unfavourable cases, instead of an 
improvement taking place at the end of the first week, the symptoms both 
local and general become more pronounced ; the amount of urine increases. 
the pulse is weaker and perhaps intermittent, the anaemia is profound, the 
breath very offensive, and oozing of blood takes place from the mouth and 
nose. The patient gradually becomes exhausted ami refuses his food. 
Duringthe last hours of life there may he total suppression of urine, drowsi- 
ness, and extreme depression of the heart's action. 



288 lhe Specific Fevers 

Mild cases may occur in which both the local and general symptoms are 
slight. There may be membranous or yellow-coloured patches on the tonsils, 
the nasal mucous membrane remaining free and the glandular enlargement 
absent, and perhaps only a trace of albumen in the urine. Such patients 
may be seen running about with but little appearance of illness ; the local 
lesions may disappear in a few days. It is important to remember that in 
such cases paralysis may follow, or a fatal result may come about through 
cardiac failure. 

malignant Diphtheria. — Of severe and malignant cases of diphtheria 
there are several types. The attack may begin insidiously with a day or two 
of slight illness, and then alarming symptoms of cardiac failure may set in 
without there having- been any excessive local lesion. In other cases the attack 
is stormy from the very first, perhaps accompanied by vomiting, and closely 
resembling scarlet fever in its mode of attack. Within a few hours of the 
onset there is extensive swelling at the angles of the jaws, with a feeling 
of stony hardness, a foetid, sanguineous discharge issues from the nostrils, 
and it is difficult to get a view of the throat in consequence of the swelling 
and difficulty in opening the mouth. The tonsils are so swollen as to meet, 
the uvula and soft palate cedematous and covered with more or less sloughy- 
looking membrane. The temperature is usually high, being 103 to 104 F., 
and the pulse and heart's action exceedingly feeble. In the course of a day 
or two, sometimes less, the cellulitis extends, the cheeks and face become 
cedematous, and the skin pits as low as the clavicle, or even over the sternum 
and chest walls ; the patient becomes drowsy and cyanotic, and there may 
be an erythematous rash, especially about the neck and chest. Purpuric 
rashes are common in malignant cases. Death usually occurs in a few days. 
Such cases resemble malignant scarlet fever, and it may be difficult or im- 
possible to distinguish between them in the absence of a characteristic rash. 

Nasal Diphtheria. — In pharyngeal diphtheria the inflammatory pro- 
cess is apt to spread to the nasal mucous membrane, especially in severe 
cases. In some cases, however, the nasal mucous membrane is the first 
seat of the exudation, and it may never spread to the tonsils, though'it is 
usually to be found to involve the back of the soft palate and the pharynx 
more or less. In nasal diphtheria no membrane may be distinguished 
during life ; there may be only a purulent discharge with blood, the presence 
of which in the nasal passages obstructs respiration, giving rise to a bubbling 
or sniffling sound, especially during sleep. In nasal diphtheria the general 
symptoms are usually quite as severe as in faucial diphtheria, and a guarded 
prognosis must always be given. In cases in which the soft palate, 
tonsils, and nasal mucous membrane are involved, the general symptoms, 
including the depression and also the albuminuria, are well marked. In 
connection with this form of diphtheria we must bear in mind there is a 
form of membranous exudation occurring on the nasal mucous membrane 
in measles and as a primary disease which is not diphtheria, but which runs 
a much more favourable course, and in some cases at least the membrane 
formed is thinner and less adherent than it is in diphtheria. The term 
' Rhinitis fibrinosa' has been applied to these cases. In all cases in which a 
child is feverish with a discharge from the nostrils we should be exceedingly 
suspicious of diphtheria, especially if an epidemic prevails at the time. The 



Diphtheria 289 

inflammation may spread from the nose to the conjunctiva, and membrane 
may form on the palpebral conjunctiva and much purulent discharge may 
exude, while the eyelids may be much swollen. Membranous conjunctivitis 
is not usually diphtheritic, but due to some local irritative process; the 
local disturbance may be severe, while the constitutional symptoms are slight. 

laryngeal Diphtheria. — The larynx may be the seat of the local mani- 
festations of diphtheria in the first instance, or may become involved 
secondarily to the fauces or other part. The child may in the first place 
suffer from sore throat and feverishness for several days, and then a metallic 
cough and some dyspnoea will suggest the onset of laryngeal complications. 
Less often some other part is the first to be involved; thus we have known a 
patch of membrane to make its appearance at the seat of an eczema, and 
then a few days afterwards a diphtheritic laryngitis supervene. We have 
already described (p. 192) the symptoms present in laryngeal diphtheria. 
We must constantly bear in mind that the obstruction to the air passages 
caused by the presence of membrane in the larynx or trachea may modify 
or overwhelm the symptoms of the disease, but we must not overlook the 
tendency to heart failure or the depression, as well as the possibility of 
uraemia or paralysis supervening. 

Wound Diphtheria. — Diphtheritic membrane may be present on the 
lip, tongue, vulva, and glans penis. The diphtheria bacillus is, however, 
apparently unable to flourish on normal skin ; but when the cuticle is 
abraded, as after blistering or in eczematous conditions when a moist raw 
surface is present, the bacillus readily flourishes. Granulations also afford a 
congenial soil. The bacillus may be inoculated during an operation — as, for 
instance, in excision of the tonsils ; we have seen a case in which membrane 
formed within twenty-four hours of an operation for hypospadias at the seat 
of operation, a fatal result occurring in a few days. We have several times 
seen membrane form on granulations at the external wound in empyemata. 
In one of these cases a fatal result followed. In tracheotomy for diphtheria 
the wound and skin around the wound are apt to become the seat of a 
fibrinous deposit, the inoculation taking place by the sputa coughed through 
the tube. In newly born infants the granulating" surface left after the sloughing 
of the cord may become the seat of a diphtheritic inflammation. 

Complications and Sequehc. — These, though less numerous than those 
occurring after scarlet fever, arc hardly less important. There is the ex- 
tension of the inflammatory process from the fauces to the neighbouring 
parts already referred to — viz. to the larynx, nose, middle ear, and lymphatic 
glands ; the latter may suppurate besides these. The most noteworthy are 
the following : 1st, albuminuria and uraemia ; 2nd, pneumonia ; 3rd, disturbed 
innervation of the heart ; 4th, paralysis. 

1. Albuminuria can hardly be said to be a complication of diphtheria. 
inasmuch as it is almost constantly present at some time or other of the course 
in faucial, nasal, and laryngeal diphtheria. It is, however, frequently absent 
in mild cases of wound diphtheria. In some epidemics, according to some 
observers, albuminuria is much commoner than in others. Our experience 
certainly has been that albumen is rarely absent from the urine in cases of 
true diphtheria. The albumen usually makes its appearance from the third 
to the eighth day. The urine is mostly normal in colour and in amount, but 

U 



290 The Specific Fevers 

a few blood corpuscles and epithelial casts may be found on microscopical 
examination in many cases. In some malignant cases hematuria may be 
present. The amount of albumen present forms a rough indication of the 
severity of the case ; at least after the disease has existed for a few days. 
The albuminuria is due to the changes effected in the blood or in the renal 
epithelium of the kidney by the albumoses or toxalbumens present in the 
blood, and the amount of albumen in the urine represents to some extent 
the amount of poisoning going on. Suppression of urine and uraemia 
occur at times, though the symptoms present are not so distinctive as in 
scarlet fever, as death mostly takes place before the symptoms become well 
marked. Vomiting, perhaps persistent, should always suggest uraemia ; the 
urine may become scanty and loaded with albumen, and perhaps cease to be 
secreted twenty-four or forty-eight hours before death. GEdema, muscular 
twitchings, or uraemic convulsions are rare. In cases which recover traces 
of albumen may remain for months, but chronic kidney disease as a result of 
diphtheria is rare. 

2. In severe cases of diphtheria, pneumonia in the catarrhal form is 
common, and is the result of an extension of the inflammation from the 
fauces or larynx to the lungs. It is found in nearly all cases of fatal laryn- 
geal diphtheria. It is often haemorrhagic. 

3. In all severe cases at the height of the attack the pulse is feeble and 
for the most part rapid. It sometimes happens at this time that the heart's 
action becomes irregular, intermittent, or abnormally slow. This condition 
is, however, more common during convalescence, or at least when the mem- 
brane is disappearing and the patient apparently improving. There is often 
dyspnoea on the slightest exertion, an intermittent cantering action of the 
heart, and frequently vomiting. Sudden cardiac syncope is apt to take 
place. This may occur from any unwonted mental disturbance or from 
some slight exertion, such as getting out of bed or sitting up to use the 
chamber vessel. With an irregular action of the heart there is often dyspnoea ; 
frequent vomiting and slow pulse during convalescence from diphtheria are 
symptoms of great gravity. 

4. A peculiar form of paralysis is apt to follow not only diphtheria, but 
also other febrile disorders, as typhoid fever, measles, and erysipelas ; it is, 
however, very much more common after diphtheria. The paralysis comes 
on in the majority of cases during convalescence, mostly between the third 
and fifth weeks ; it appears to follow mild cases as often as it does severe ones. 
Its usual course is to attack the soft palate, the first symptoms being a return 
of fluids through the nose, perhaps only a few drops, and a nasal twang in 
speaking ; an examination of the soft palate shows that its movements are 
less free than usual. In many cases a slight paresis of the soft palate, which 
may pass off in the course of a week or two, is the only evidence of post- 
diphtheritic paralysis. In other cases the paresis is much more decided ; when 
the patient attempts to swallow any fluid, much of it returns through the 
anterior nares, and some may perhaps enter the glottis, giving rise to a fit of 
choking. Other parts ma)- become affected — the pharyngeal muscles and 
oesophagus, so that deglutition is performed with difficulty and the patient 
has to be fed through a soft catheter. The pupils may become dilated and 
unequal from paresis of the circular fibres of the iris, there is impairment 



Diphtheria 29 1 

oF vision, from the ciliaris muscle being affected. The paresis may extend 
to any or all of the voluntary muscles, so that the patient is unable to 
stand or sit up in bed or even raise his head. Further, the respiratory 
muscles, the intercostals, and diaphragm may be affected, in most instances 
speedily producing a fatal result. It must be borne in mind that in post- 
diphtheritic paralysis there is rarely complete paralysis, but rather a partial 
loss of power, combined with numbness and sensations as of prickings with 
* pins and needles.' Both rectum and bladder may also become paralysed. 
It is important to bear in mind that paresis may. follow very mild cases, so 
that the patient may be seen for the first time when suffering from the 
paresis and make no mention of sore throat. Such cases especially if there 
be no paresis of the soft palate, may be very puzzling, and, if there be weakness 
of the legs and staggering gait, may be mistaken for tumour of the cerebellum 
or ataxy. The knee reflex may be absent in such patients, and be many 
months before it makes its reappearance. 

Diagnosis. — The diagnosis of diphtheria in a typical case does not 
present much difficulty, especially if an epidemic is prevailing. The false 
•membrane on the fauces, and the presence of albumen in the urine, render 
the diagnosis of diphtheria practically certain. But there may be a fibrinous 
exudation on the fauces with more or less fever ; no urine can perhaps be 
obtained, or, if obtained, it may contain no albumen, and we may be in 
doubt about the diagnosis. There may be a membranous exudation on the 
tongue, lip, nasal mucous membrane, or conjunctiva, with no marked con- 
stitutional symptoms, and we may be in doubt as to the nature of the case. 
In such cases clinical distinctions may entirely fail us, it being uncertain if 
the case in question is one of mild diphtheria or not. We may be entirely 
•dependent for a diagnosis on the detection of the D-bacillus in the membrane 
or secretions. If we can by microscopical examination or by cultivation in 
blood serum demonstrate the presence of LoefBer's D-bacillus in the mem- 
brane, the diagnosis is certain ; if, on the other hand, only streptococci or 
staphylococci are present, the case is not one of diphtheria (see Appendix^ 
In cases of 'croup' or ozaena an examination of the secretions, which may 
be non-membranous, may often decide the diagnosis in favour of diphtheria. 
The disease of the throat most likely to be confounded with diphtheria is 
•croupous or membranous angina ; usually, however, in this disease there 
is no tendency to spread to the nasal mucous membrane or the larynx. 
and there is less often glandular enlargement. The onset is more sudden ; 
the urine is free from albumen. It is unnecessary, perhaps, to add a word 
of caution in not excluding diphtheria without very good reason. No 
albumen may be present in the urine at the time of examination, but be 
present later ; there may be a complete absence of constitutional symptoms, 
and yet diphtheria be present. A mild case of diphtheria in a household 
may be followed by a malignant one. Diphtheria is distinguished from 
scarlet (evev by the absence of the rash, though an erythematous blush is 
present in a few cases. In malignant scarlet fever the rash may he absent. 
and the glandular swelling and sloughy condition oi the throat closely 
resemble diphtheria ; there may also be a fibrinous exudation as well as 
albuminuria. Diagnosis is often impossible. The punctiform rash, however, 
is rareh absent in scarlet fever. 



■■ 



292 The Specific Fevers 

Prognosis.— Diphtheria is one of the most fatal diseases with which we 
have to deal ; but the mortality differs widely in different epidemics. The 
most fatal is undoubtedly the laryngeal ; of these probably not more than 
one case in ten recovers without operation — by coughing up the membrane. 
In faucial diphtheria the mortality may be as high as 75 per cent. ; the 
younger the child the worse the prognosis. The strong and hitherto healthy 
share the same fate as the weakly. Of especially bad augury are large 
quantities of albumen in the urine, much glandular enlargement, excessive 
nasal discharge, a foetid state of the fauces, vomiting, and suppression of 
urine. A sudden fall of the temperature to subnormal, and an intermittent 
pulse, are also extremely bad symptoms. Recovery from a severe attack in 
which there is great depression and much albumen in the urine is excep- 
tional, especially in a child under six years of age. Recovery does, how- 
ever, take place at times in apparently hopeless cases. Suppression of 
urine in diphtheria is nearly always fatal ; though in one case seen by us r 
in which the boy had suppression of urine and nasal haemorrhage, recovery 
finally took place. A fill of temperature in scarlet fever in the absence of 
nephritis is a good sign ; it is by no means so in diphtheria, especially if 
vomiting be present and an increasing quantity of albumen. 

Treatment. — The indications for treatment are the following : 1st. To 
isolate the patient in the most airy room obtainable. 2nd. To apply anti- 
septics to the fauces or affected parts in order to destroy the bacilli and 
other micro-organisms, and to prevent decomposition and fcetor. 3rd. To 
antagonise the poisons absorbed into the system or formed in the blood. 
4th. To support the strength of the patient, and to treat symptoms as they 
arise. 

1 st. The patient may be isolated by sending him away to a hospital for 
infectious diseases, and this is often the best and simplest plan, but it is not 
always possible. If the patient is to remain at home, the largest room 
available on the top landing should be selected, or, still better, two rooms 
adjoining one another, so that the patient can be moved from one to the 
other, thus allowing the unused one to be ventilated. The supply of a large 
quantity of fresh air to the patient is of the first importance. All other 
children in the house should be sent away, bearing in mind, however, that 
they may be incubating the disease, so that they should not be sent where there 
are other children, or to a distance where they cannot be brought back again 
in case they fall sick. Arrangements should be made for disinfecting all the 
excretions and bed linen of the patient. 

2nd. There can be no difference of opinion as to the importance of 
applying antiseptics to the fauces in order to wash away the mucus, decom- 
posing blood, and remains of food, and to destroy as far as possible the 
micro-organisms. It is needless to say that this antiseptic treatment to be 
of any service should be begun early in the disease ; we can have but 
little hope of influencing the course of the disease by local treatment in the 
later stages, but something can be accomplished even then by cleansing the 
mouth of foetid and decomposing matters. To properly carry out the local 
treatment trained nurses are necessary, as the patient's friends rarely have 
the necessary skill or the firmness to effectually carry out the details 
properly ; unfortunately, it often happens that even skilled nurses may fail 



Diphtheria 293 

to accomplish all that we could wish, on account of the fractiousness of the 
patient. The mucus accumulating in the pharynx and nostrils should be 
removed by means of a mop of cotton wool attached to a stick, and the 
antiseptic may then be applied by means of a steam spray, such as Siegel's, 
or by a hand spray. Failing this, a ball syringe may be used, large enough 
to hold 5 or 6 oz., the child's head being held forward so that the fluid may 
run out of its mouth. It may be impossible without a struggle to apply 
•either of these ; in such cases we must be satisfied by the insufflation of 
antiseptic powders, as sulphur or iodoform and boric acid, or calomel and 
boric acid. Ice is useful to suck, and the food may be given iced. 

With regard to the success of local treatment in pharyngeal diphtheria, 
we must remember that many bacilli are present in the mucus secreted, and 
also in the epithelium, whilst others are embedded in the fibrinous exuda- 
tion. We cannot reasonably hope for the destruction of all the bacilli 
present, especially those in the membrane, by spraying or washing out the 
throat by antiseptic solutions. To more effectually apply antiseptics, Dr. 
A. Siebert, of New York, has devised a sort of syringe provided with a 
number of hollow needles, by means of which some antiseptic fluid can 
be applied into and underneath the membrane. Among the effectual 
antiseptics or germicides are solutions of corrosive sublimate (1 to 1,000), 
•carbolic acid (1 to 100), salicylic acid (1 to 1,000), chlorine water, and Condy's 
Fluid. Solution of peroxide of hydrogen is also useful, and certainly corrects 
the foetor effectually. Probably corrosive sublimate is the most effectual of 
all, but it has the disadvantage of being poisonous, and it has an unpleasant 
metallic taste. We have known it when used for mopping (1 to 500) produce 
mercurial stomatitis ; there can, however, be little fear of this if used well 
diluted and with caution. For painting the fauces we use glycerin acid, 
carbolici one part, with two parts of tr. iodi. Loeffler has recently recom- 
mended a 10 per cent, solution of menthol in alcohol, adding 4 per cent, of 
perchloride of iron. 

Calomel fumigation, as described on p. 196, is a convenient way of using 
mercury. 

Dry applications are preferable to lotions in wound diphtheria, as the 
latter are apt to fret the skin and leave a suitable soil for the bacillus to 
flourish on. Salicylic acid and starch (1 to 20), calomel and starch, or 
iodoform and boric acid answer very well. It is a good plan to vaporise 
•carbolic acid in the sick-room from time to time. 

3rd. The ' scrum treatment,' which we owe to the patient investigation of 
lichring and Roux, appears likely to take a permanent and important place in 
the treatment of diphtheria ; whether this k heilserum ' acts by rendering the 
tissues 'immune' or by antagonising the diphtheria ptomaines is at present 
an open question. In any case it is of the greatest importance to commence 
the treatment as soon as the diagnosis of diphtheria is made with certainty. At 
the present time no directions can be given with regard to dose, as the dose 
depends upon the strength of the serum, and this appears to differ widely. 
No evil effects have been recorded from the serum injections, but erythema, 
urticaria, and joint pains have been noted by some observers. The local 
treatment of the throat should be continued during the injections. 

We have no great belief in the efficacy ol either mercuric bichloride or 



294 The Specific Fevers 

potassae chlorat. taken internally in diphtheria ; the latter is undoubtedly 
dangerous, as Dr. A. Jacobi long ago pointed out. We prefer to use the 
old-fashioned tr. ferri perchlor. in three to five minim doses every four hours. 
It maybe given in lemonade, soda water, or in any way in which the patient 
will take it. Digitalis, caffeine, coca wine, alcohol, should be given from 
the first if there is much depression of the system, and in the worst cases 
alcohol in the form of brandy or port wine must be given with a free 
hand. 

4th. The diet supplied to the patient must consist of the most concen- 
trated form of nourishment possible, as in most cases there is great difficulty 
in getting him to take food on account of the discomfort and pain in swallow- 
ing ; beef juice, peptonised meat preparations, milk, and nutrient supposi- 
tories may be needed. If there is swelling or cellulitis, the neck should be 
painted with glycerine and belladonna and covered with cotton wool. If the 
glands suppurate, incision and proper drainage must be resorted to. The 
greatest care must be exercised during convalescence to supply the patient with 
suitable food and fresh air, and to prevent any exertion on his part. Paresis of 
the soft palate, general paralysis, and failure of the heart may come on at 
any time within a month or five weeks of the commencement even in mild 
cases, and the practitioner should constantly be on his guard, and warn the 
friends against allowing any excitement or unwonted exertion. During con- 
valescence quinine, strychnine, and iron should be given. The continuous 
current and massage is of use in the paralysis which follows. Change to the 
seaside after five or six weeks reckoned from the commencement of the 
attack will prove of great benefit. 

Quarantine. — This should be maintained for three weeks in mild cases., 
and a month or more in the more severe attacks. 

Disinfection. — A temperature of 6o° C. in a moist atmosphere is sufficient 
to destroy the D-bacillus. For disinfection the simplest way is to boil the 
linen removed from the patient, and treat his clothes, as far as possible, in 
the same way. The furniture of the rooms in which he has been should 
be scrubbed with hot water and carbolic soap, and the floors and walls, 
should be treated in like manner. Wearing apparel which cannot be boiled- 
had best be destroyed. 

Pseudo-diphtheria 

Practitioners have long been familiar with a form of sore throat which 
mostly occurs in epidemics, which in many ways resembles diphtheria, but for 
the most part runs a milder course, and is not followed by the serious 
sequelae which so often follow diphtheria. Such cases have gone by the nam 
of diphtheritic sore throat or ' croupous angina.' Recent observations have 
shown that the D-bacillus is not the only micro-organism which is capable of 
giving rise to fibrinous exudations, but, at the same time, no other micro- 
organism is apparently able to produce the depression, albuminuria, and 
paralysis ivhich so often accompany true diphtheria. Given a suitable soil, 
several kinds of cocci, especially the Streptococcus and Staphylococcus pyogenes y 
are able to produce an inflammatory sore throat with more or less fibrinous 
exudation; there is also, according to Klein, a 'pseudo-diphtheria bacillus 
closely resembling the true bacillus in its histological characters, but incap- 



Epidemic Influenza 295 

able of generating during its growth the toxic albumens produced by the 
true bacillus. Cases of pseudo-diphtheria may be mild with only slight 
fever, but, on the other hand, they may commence with vomiting, high fevers, 
rigors, and the tonsils may be swollen and covered with a membranous 
exudation. The mortality is not high, being very much less in diphtheria, 
but fatal cases do occur, sometimes from pneumonia. The clinical course of 
such cases may be very much like what has already been described under 
acute tonsillitis. Fibrinous exudation may occur in other places, as on the 
nasal mucous membrane, tongue, lip, vulva, conjunctiva, in connection with 
measles or other diseases, caused by septic cocci as well as by the D-bacillus. 
The one important point in connection with these cases is necessarily the 
diagnosis. If we can certainly exclude diphtheria, the relief to all concerned 
will be great. Clinically this may be impossible, and a diagnosis may only 
be made by demonstrating the absence or presence of the D-bacillus in the 
exudation or secretions. But difficulties may occur here as long as the 
question as to the existence of a pseudo-diphtheria bacillus, and its dia- 
gnostic characters, is unsettled. In spite of the greatest care, even the most 
experienced physicians may in some cases remain in doubt as to the presence 
or absence of the diphtheria bacillus in a given case of an uncertain cha- 
racter. The local treatment of pseudo-diphtheria is much the same as that 
for diphtheria, antiseptics being employed to destroy the cocci and to keep 
the fauces and mouth sweet. Carbolic acid, salicylic acid, peroxide of 
hydrogen, and chlorine water, are among the most suitable. On the skin, 
starch and salicylic acid powder answers very well. All such cases should 
be isolated ; indeed, every case of tonsillitis occurring in children should be 
regarded with suspicion and kept away from its fellows during both the 
febrile and convalescent stages. 

Epidemic Influenza. 6 la Grippe ' 

During the last two or three years the British Isles, in common with the 
continents of Europe and America, have been visited by epidemics of a 
peculiar zymotic disease, which has received various names, but is best known 
in this country as 'epidemic influenza.' These epidemics have been wide- 
spread, affecting a number of people at the same time, have come to an end 
in a few months, and then reappeared in the following year. It is very in- 
fectious, its incubation is short, and, unlike most zymotic diseases, one attack 
does not protect from attacks in subsequent epidemics. It is very prone to 
relapse. In some epidemics in past times children appear to have escaped 
to a large extent, having been apparently less susceptible than adults. This 
does not seem to have been so in the recent epidemics, for individuals of all 
ages have been promiscuously attacked, children having been affected in 
common with adults, though the mortality among the former has not been 
so high as among the latter, especially in the pneumonic form. In some 
epidemics children have apparently escaped till late in the epidemic. The 
incubation is usually a short one, often not more than a few hours, though it 
may be longer. Certainly cases occur in which a very few hours after the 
arrival in a household of an infected individual some members oi the house- 
hold are quickly attacked. The disease appears mostly to spread by direct 



296 The Specific Fevers 

contagion, and the difficulty of controlling an epidemic arises from the fact 
that a number of mild cases occur which do not confine the patient to his 
bed or to the house, so that while going about his business as usual he readily 
disseminates the disease. R. Pfeiffer l has successfully cultivated the in- 
fluenza bacillus on blood-agar — that is, an agar medium containing haemo- 
globin. The bacillus occurs in large quantities in the mucus coughed up. 

The difficulty in describing the symptoms consists in the absence of any 
very characteristic ones, and in the multiplicity of symptoms which may be 
present. Moreover, the type of attack appears to alter from time to time 
and in different localities. The diagnosis has, in point of fact, often to be 
made by a process of exclusion, aided greatly by the knowledge that an 
epidemic of the disease is prevailing at the time, and that perhaps other 
members of the household have recently suffered. As a result of the difficulty 
of diagnosis, there cannot be a doubt that many cases in which the diagnosis 
was doubtful have been described as influenza, inasmuch as the disease was 
prevailing at the time ; and thus it has come to pass that much confusion has 
arisen, and much that has nothing to do with influenza has been included in 
the descriptions of this Protean disease. We are far from denying that 
influenza may not be the cause of diverse forms of inflammatory lesions ; 
we know the so-called pneumonia diplococcus is able to excite not only a 
pneumonia, but also an otitis and meningitis, and it is by no means impossible 
that the influenza micro-organism may at one time excite a pneumonia and 
another time an enteritis or meningitis. The cases in which the greatest 
difficulty in diagnosis occur are in infants and young children. It is so 
tempting to attribute an indefinite febrile attack in an infant to teething or 
dyspepsia, and so difficult to be certain that the attack is due to influenza, 
unless another case crops up in the same household to give us the clue. In 
infants we have not the advantage of the patient's account of himself as we 
have in adults, so that the diagnosis is often only come to with difficulty. One 
of the commonest forms of the disease in infants and young children is the 
simple febrile type. Practically the only prominent symptom is fever. The 
infant is noticed to be hot, there is a temperature of 102 or 103 F., the 
pulse and respirations are accelerated, it is heavy and drowsy, and then, after 
a few days or a day or two, the temperature falls, and the infant is prac- 
tically well again. In many cases the course is protracted, the temperature 
going up every evening for a week or more before it finally settles down to 
normal again. In more severe cases the fever suddenly runs up to 104 or 
105 (it may be with a convulsion or vomiting), then for days or weeks there 
may be fever of a remittent or intermittent type, without there being any 
pneumonia or tubercle or enteric fever to account for the temperature. 
Finally, a good recovery is made. These cases are often very puzzling, 
especially the protracted ones, and we may call in question our original 
diagnosis of influenza, and begin to fear there may be an acute tuberculosis 
in progress : in all such cases it is, of course, necessary to repeatedly examine 
the lungs, and to bear in mind the possibility of an erratic enteric fever being 
present ; there cannot be a doubt, however, that in young children a fever 
of the intermittent type, lasting two or three weeks or more, may be due to 
the influenza bacillus. Convulsions and vomiting are among the frequent 
1 R. Pfeiffer, Zeitschrift fur Hygiene : Infektionskr. 13-357. 



Epidemic Influenza 297 

symptoms in infants and young children, possibly suggesting an acute 
meningitis ; the vomiting is often exceedingly troublesome at times, but 
the worst cases of this type occur in older children. In others there may 
be bronchitis and pneumonia of a depressing and fatal character. We 
have not seen many fatal cases in infants apart from pneumonia, but in 
one case that we know of death occurred in two days as the result of 
an attack which was accompanied by high fever and depression. The 
infant was ten months old, and its mother was suffering from influenza at the 
time. 

In older children the attacks approach more nearly the types of attacks 
witnessed in adults. But as a general rule the neuralgic pains are less 
marked, as also are the rigors and backache. The attack is sudden, the 
temperature running up to 103 or more, there is severe headache, vomiting, 
chilliness, and often sore throat. The conjunctivae are injected and the 
child has a heavy look. Earache is often a marked symptom. After twenty- 
four or forty-eight hours of more or less high fever, the temperature falls to 
normal or it runs a lower course. Some cough remains for a few days, and 
often marked depression ; but this, in our experience, is not so severe as in 
adults. An examination of the fauces will often show them to be injected, 
and the tonsils enlarged and covered with yellow points ; there may be some 
glandular enlargement secondary to the tonsillitis. To add to the difficulties 
•of diagnosis, these cases sometimes have a red rash closely resembling- 
scarlet fever. In some cases which we have seen, we had no doubt that 
they were influenza and not scarlet fever. This conclusion being arrived at 
rather from the fact that influenza was epidemic and there were cases in 
the same household and neighbourhood, than from being able to decide 
from the symptoms and examination of the patient. Kramsytyk records an 
•epidemic of influenza in Warsaw, accompanied by a red rash ; on the other 
hand, Filippow records sixteen cases in which influenza was complicated by 
scarlet fever. There may be an attack of the simple febrile type, already 
described as affecting younger children. 

One of the most serious forms which the disease can take is that in which 
vomiting is a prominent symptom. In some of these cases the fever is high, 
perhaps 104 or 1 05 F., there may be delirium or an excited state of the nervous 
system, the conjunctivae are injected, and the child restless and sleepless. 
Such a case will often suggest an acute meningitis. The vomiting is often 
continuous, and gradually exhaustion comes on. In one fatal case of this 
character which we saw the temperature was not high, not exceeding 102 F., 
and this for a time made the diagnosis of influenza doubtful. In the worst 
•cases the vomiting continues unrelieved, and the child dies of exhaustion or 
in a convulsion. At the post-mortem no gross lesion is found, but there is 
usually venous congestion and marked injection of the venous capillaries. 
Another serious complication is pneumonia ; this may be either o( the 
croupous or broncho-pneumonic type. The course is often protracted, and 
the mortality is higher than in the ordinary forms of pneumonia. Empyema 
is not an uncommon result. Less commonly there is a catarrh ol the small 
or large bowel, giving rise to troublesome diarrhoea and colic. We have 
seen several cases of acute ileo-colitis which occurred during an epidemic o( 
influenza, but we could not for certain say they were due to this cause. We 



298 The Specific Fevers 

have seen cases that certainly resembled enteric fever. Meningitis has been 
described as occurring in some attacks (G. W. Earle). Severe otitis is not 
uncommon. Relapses are common, and the possibility of their occurrence 
will always have to be borne in mind. We have known death to take place 
in a relapse. As a rule, the depression which so commonly follows an 
attack of influenza in an adult is much less marked in the case of children. 

Sequelce. — Chronic otitis is apt to be left by influenza. Various nervous 
sequelae may occur, more especially in adults. We have seen cases in which 
an irregular and intermittent action of the heart was left by attacks of influenza 
in children. Recovery seems always to take place. 

Treatment. — The patient should be isolated, and confined to bed in a 
well-warmed room. As long as the fever lasts his diet|should consist of 
fluids, such as beef tea and warm milk. As a routine method of treatment 
we generally prescribe a mixture containing salicylate of soda, antipyrin, and 
spirits of chloroform. If the fever is high, vigorous antipyretic measures 
may be required ; to this end warm or tepid baths, with doses of phenacetin > 
antipyrin, or antifebrin, may be given. Other symptoms must be treated as 
they arise. The most difficult cases to treat are those in which the vomiting 
is a constant symptom. In these cases antipyrin in an effervescing, mixture^ 
iced champagne, and small quantities of raw beef juice may be tried. In 
the continued fever salipyrin and quinine may be given. 

Enteric Fever 

As a general rule it may be said that children and young people are 
more susceptible to enteric fever than are adults, and they usually suffer 
from it in a milder and less complicated form. It is not common in children 
under three years of age, though it undoubtedly does occur even in infants, 
and may be fatal ; it is not easy to say at what period of life it is most 
common, as statistics of fever hospitals are apt to be fallacious, since the 
milder cases are certain to be nursed at home, and children suffering from 
the disease in a mild form will in a great many cases never enter a hospital 
at all. According to Collie, ten years to twenty years of age is the commonest 
time for an attack ; five years to ten years of age ranking next. The mortality 
at all ages from enteric fever, according to Murchison, is 15 to 20 per cent. 
In children, according to Barthez and Rilliet and Gerhardt, 10 per cent. In 
our own hospital 592 cases have been treated, with 48 deaths, giving a 
mortality of 8 per cent. It is obvious that too much reliance must not be 
placed upon these figures, as in the different hospitals a different proportion 
of severe cases may be admitted, or the mild and abortive cases may or may 
not be reckoned as attacks. 

Enteric fever spreads by direct contact with the sick, by means of 
emanations from both fresh and stale fasces, possibly also by the breath, by 
inhalations of sewer gas given off from drains into which the excretions of 
enteric patients have been thrown, and by the taking of drink or food which 
has become contaminated by the specific bacilli. There is reason to believe 
that infection may be carried from the sick to the healthy on the fingers or 
clothes of a third person. The evidence that enteric fever is directly con- 
tagious, the disease being contracted by coming in contact with a patient, is 






Entt 



F 



299. 



too strong to be explained away— notably the evidence produced by Collie 
at the Homerton Fever Hospital ; and in our own hospital hardly a year 
passes without one or more probationer nurses contracting the fever from 
patients they are nursing ; and we have known it to happen that patients in 
the same ward with cases of enteric fever, who have never been out of bed. 
have contracted the fever, doubtless by the bacillus having been brought to 
them by one of the attendants. It appears to spread in this way in the 
crowded homes of the poor, where one member, mostly one of the children, 
contracts the disease, and remains at home, being nursed in a room where 
others sleep ; then in the course of two or three weeks other members are 



iliisiisSssil 










Fig. 



-Temperature Chart of a case of Mild Enteric Fever in a boy aged 9 years. 



attacked. Indeed no disease is more certain to spread in the crowded 
dwellings of the poor than enteric fever. 

Incubation. — Usually fourteen to twenty-one days. 

Symptoms and Course.— In every epidemic cases may be met with \\ hich 
are so mild that they can only be recognised as enteric, as they occur in the 
same house with other undoubted cases. In such cases the temperature 
may be from first to last intermittent, being perhaps 102" or 10 v in the 
evening, and falling nearly to normal the following morning : evidently these 
cases were included by the older writers under the term 'infantile remittent 
fever.' Other cases, which begin like an ordinary attack, abort by the end 
of the second week, and are at once convalescent without going through the 
ordinary three weeks 1 course. In other cases the morning remission is much 
more marked, being perhaps three or four degrees lower than the evening, 



300 The Specific Fevers 

and this tendency is especially shown after the middle of the second week. 
In these mild cases the patient does not appear ill ; in the morning the child 
will be seen sitting up in bed playing with his toys ; and but for a heavy look 
about the eyes and a glance at the temperature chart over the bed, it would 
be difficult to persuade oneself that he was suffering from any febrile disease. 
Such patients are often brought to the out-patient rooms of dispensaries, and 
are not considered by their parents as anything but ' out of sorts.' There is 
rarely diarrhoea in the milder cases. On the other hand, cases of great 
severity may be met with in children, the fever may run high and last for 
many weeks, or fatal complications may supervene, or death may take place 
•early in the disease from the intensity of the poison, as in the case of a child 
of three years coming under our notice who died as early as the eighth day. 

Initial Symptoms. — These mostly come on gradually, though exceptionally 
there is a somewhat sudden onset ; the fact that the onset in any case has 
been abrupt does not certainly negative the diagnosis of typhoid fever. 
Frontal headache is nearly always complained of, with a feeling of chilli- 
ness which induces the patient to sit over the fire ; there is usually ' rambling ' 
at night, less often abdominal pain, diarrhoea, and epistaxis. 

Te7nperature. — In an attack of ordinary severity the evening temperature 
reaches 104 by the fourth evening, continuing to reach this point or there- 
abouts oncejdaily for about ten days, the diurnal remissions usually being i° 
to 2 ; the remissions then become more marked, amounting to 2 or 3 , the 
fever gradually subsiding by lysis, and of an intermittent type, remaining 
normal after the twenty-first day (see fig. 45), though perhaps touching normal 
a day or two before. The highest temperature of the twenty-four hours 
is usually late in the afternoon at 4 or 5 p.m. ; later in the attack it is post- 
poned, and reaches its highest point at 8 P.M. or midnight. In mild 
-attacks there is a marked tendency to remit 2° or 3 or more early in the 
attack, and to abort at the end of the second week, in a way which is rare in 
adults. 

Hyperpyrexia is the exception in children ; in a few cases a temperature of 
105 or even 106 maybe reached, but the usual maximum temperature during 
twenty-four hours in the first ten days is 103 to 104 . 

The temperature curve of a relapse differs very much in different cases ; 
it is usually of a remittent type. It is hardly necessary to insist that the 
temperature should be always carefully taken during enteric fever, as it 
affords the best index we possess of the severity of the disease or the patient's 
progress to recovery. 

Tongue and Mouth. — During the first week there is usually nothing 
characteristic about the tongue ; it is coated with a thin white fur, but is 
clean and moist at the edges ; there is often a glazed clean strip down the 
centre. It may remain moist and furred throughout, while later, especially 
in cases of moderate severity, the tongue is covered with a brown fur, dry, 
with a brownish glazed central strip. Later the tongue becomes clean, red 
and glazed ; sometimes there are superficial ulcerations on the surface. 
Sordes very readily collect on the teeth, and the mouth becomes foetid if 
not cleansed. 

Abdomen. — The abdomen does not become distended till the end of the 
first week ; during this time the distension gradually becomes more and 



Enteric Fever 



301 



more marked from the accumulation of gases in the small intestines ; at 
the same time a certain amount of pain on deep pressure may be elicited 
and gurgling detected in the iliac fossae. By the end of the third week, if 
the temperature has become normal, the abdomen becomes less rounded, and 
gradually returns to the normal condition. In mild cases the abdomen may 
be normal from first to last. 

Spleen. — The spleen usually enlarges during the first week ; the earliest 
day on which we have felt it to be enlarged was in one case on the sixth day. 
It continues enlarged and somewhat soft during the pyrexia ; according to 
Jacobi, if the spleen remains enlarged after the temperature has fallen, a 
relapse is to be feared. In some cases there is no enlargement to be felt 
during life, and the post-viortcm has revealed a spleen of normal size. 





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Fig. 45. — Temperature Chart ofa case of Enteric Fever in a girl aged 9 years. 
* rose spots ; f spleen felt. 



Bowels. — Typical 'pea-soup' stools are the exception in children, certainly 
diarrhoea is not usually a prominent symptom. The bowels may be con- 
stipated or normal, they may be simply loose, or there may be the watery 
pea-soup stools characteristic of the disease. As a rule it is the severe cases 
which have troublesome diarrhoea, but cases may be severe with high tem- 
perature and prolonged course without diarrhoea being present. During con- 
valescence constipation is apt to be troublesome, on account ot the atony of 
the bowel left by the disease. 

Cerebral Symptoms. Slight delirium at night with a tendency to talk 
and chatter nonsense is common : acute delirium like that present in typhus 
or acute pneumonia is rare. After a severe attack the mind sometimes 
remains weak, a condition of dementia existing for some weeks : sometimes 



3<D2 The Specific Fevers 

.aphasia is left ; more often the loss of speech is due to mental weak- 
ness. The prognosis is good, the mind recovering as the system gathers 
strength. 

Eruption. — The characteristic rose spots are present in about 75 per cent, 
•of the cases. The spots may be detected by the end of the first week, rarely 
earlier ; fresh spots appear daily till towards the middle of the third week ; 
they may go on longer, into the fourth or even fifth week. They often re- 
appear during a relapse. Their numbers vary from two or three to many 
"hundred, so that the child has a freckled appearance. 

Urine. — If the temperature is high and continuous, albumen in slight 
quantity is mostly present. Indican is often present. The urine is high- 
coloured and concentrated. 

Complications. — The same complications that occur in adults are found 
also in children. There is the same tendency to relapse, there may even 
be more than one. Not infrequently the relapse is more severe than the 
primary attack ; death from perforative peritonitis may take place in a 
relapse. The interpyrexial period is very variable. Thus in a severe case 
the temperature touched normal on the twenty-first day. was then intermittent 
till the thirtieth, then normal till the thirty-fourth, then a relapse occurred, 
the temperature varying from 102 to 104 , till it reached normal again on 
the fifty-third day ; recovery followed. In another case the primary fever 
ended on the nineteenth day, a relapse occurred on the thirtieth, lasting till 
the fiftieth. In another the primary fever ended on the twentieth, the relapse 
occurred on the twenty-eighth, and lasted till the forty-second. In another 
the primary fever ceased on the twenty-fifth, and a relapse occurred lasting 
from the twenty-seventh to the forty-sixth. 

Epistaxis is not uncommon as an early symptom, and is of no importance. 
Small quantities of blood in the stools are common during the second and 
third week, and if small in quantity need not be a cause of alarm. Smart 
haemorrhage from the bowels is rare, though serious when large in 
amount, yet we have not seen a fatal case result from it in a child. We have 
■seen severe haemorrhage in three cases, all, however, ending in recovery. 
In one case, a girl of eleven years, there was a fall of temperature on the 
twenty-seventh day, from 103-2° to 98-8°, followed by a haemorrhage of 
10 oz. of blood per rectum ; another haemorrhage occurred on the thirty- 
first day, and again on the thirty-second day some 12 oz. were passed ; she 
•eventually recovered. In another case, in a boy of twelve years, who was 
.admitted after having been ill a month, the same evening there was a large 
naemorrhage per rectum, sufficient to blanch his lips, and for the time he was 
^nearly pulseless ; he finally recovered. 

Bronchitis and pneumonia come on in man)" of the severe cases ; they 
•occur quite independently of a chill or from taking cold ; they are due rather 
to stasis of blood in the lungs, mostly at the bases, and possibly also to the 
local working of the specific bacillus of enteric fever. Diminished resonance 
with rales and rhonchi are detected at one or both bases if pneumonia is 
present. The temperature is usually high, and the pulse and respiration are 
increased. We have seen death take place from this cause on the nineteenth, 
twentieth, twenty-first, twenty-third, and thirty-fifth days. The pneumonic 
■king is of a purplish colour, has a solid airless feel, and is often more or less 



Enteric Fever 



303 



collapsed on section ; the cut surface is not granular like croupous pneu- 
monia, but smooth and dark red. The lung is airless, and sinks in water. 

Pyaemia, with secondary abscesses in the lungs and elsewhere, the result 
of septic embolism from the ulcers in the intestines, occasionally occurs. In 
four of such cases dying in the Children's Hospital, the course of the disease 
was acute, with hyperpyrexia and an intermittent temperature towards the 
close ; one died on the nineteenth day with suppuration in the parotid, the 
others on the twenty-fifth, twenty-ninth, and thirty-seventh day respectively. 
At the post-mortem pyyemic abscesses due to infarcts, and pneumonia were 
found. 




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BSSSBSSi BSRS 

ISisSsisSSB SSSSisifSSSBBRlsSSBRSSS 



iiiiiiiiiiiiiiiiiiiiiii 



mmmmm 

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SBB-fiBiBls»SBSS§SBi 
iSSSSSSSSS 



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liflyiiiiiiliiiiiiiiiliiliiiiiliiiii 
iiililiiiiiiliiiiiiiiiiiiiiiiiilliiii 

liiiii iliiyiilllluliiii 



Kig. 46. — Temperature Chart of Enteric Fever ; Peritonitis ; death sixteenth day ; 
in a girl of 9 years. 

The most dreaded complication in enteric fever is perforation of the 
intestine followed by peritonitis, in consequence of an ulcer penetrating 
through the wall of the intestine. This complication is fatal with veryjew 
exceptions, though it is difficult to say if it always is, as case- with 
symptoms of peritonitis sometimes recover, and it is not unreasonable to 
suppose that at times no extravasation may take place, the affected portion 
having become glued by means ol~ lymph to another piece ot intestine. In 
four of our cases death occurred oil the sixteenth, twenty-second, thirtieth. 
and forty-eighth days respectively. In the case in which death occurred Oil 



304 The Specific Fevers 

the sixteenth day, it was not certain if it was the sixteenth day of the primary 
fever or of a relapse, as there was a history of indefinite illness before ad- 
mission. The temperature on admission was normal, though there was some 
rhonchus and rales were heard in the chest; the disease ran an acute course 
(fig". 46) for fifteen days, when suddenly there was collapse, the temperature 
falling abruptly, with vomiting and abdominal pain ; the temperature rose 
again to 104 , death occurring next day. A perforation in the ileum, three 
inches from the caecum, was found, with extravasated fasces and general 
peritonitis. In all the cases there was abdominal pain and collapse a day or 
two before death. In the case in which death occurred on the forty-eighth 
day, the girl had been ill three weeks before admission, and the attack 
treated in the hospital may have been a relapse. There was hyperpyrexia 
and intermittent fever. 

Some cases of enteric begin with tonsillitis and membranous exudation 
on the tonsils ; occasionally sloughing tonsillitis supervenes in the course of 
the attack ; this was so in one fatal case, in another a membranous laryngitis 
occurred causing death on the twenty-first day. otitis may occur, and 
occasionally a fatal result follows from thrombosis of the lateral sinus and 
pyaemia. 

Tuberculosis may complicate the course of enteric fever, or it may 
follow as a sequela. In one case a child died of pneumonia on the twenty- 
first day ; tubercles were present on the pleura and in the lung. In another 
case a girl recovered from enteric, the temperature becoming normal on the 
twenty-sixth day ; it remained normal for a few days ; she continued to im- 
prove for a month, though the temperature went up occasionally at night. 
Then hectic fever came on, with vomiting, and she died comatose three weeks 
after ; t\\epost-7tiortem showed tubercular meningitis and a few tubercles in 
the lungs. 

Diagnosis. — During the first few days the diagnosis of enteric is difficult, 
often impossible, and especially in children typhoid may be confounded with 
the feverishness which so often accompanies dyspepsia and intestinal catarrh. 
Children are frequently brought to the out-patients' rooms of children's 
hospitals with indefinite symptoms and feverishness ; a tentative diagnosis 
of enteric is made, but in a few days the symptoms disappear and the child 
is practically well again. Such attacks may be more severe, and it may be 
impossible to say whether the patient has had an abortive enteric attack or 
not, unless there are undoubted enteric cases in the household. In all doubt- 
ful cases, in the early stages, the temperature should be carefully taken every 
four hours and a careful examination made for rose spots and enlargement 
of the spleen. The diagnosis in small children and infants is extremely 
difficult, on account of the many causes, such as patchy catarrhal pneumonia, 
intestinal catarrh, influenza, and tuberculosis, which may give rise to an inter- 
mittent or remittent fever ; it must have occurred to almost every medical 
man in practice to have seen babies or young children with an intermittent 
fever lasting two or three weeks or more, with flatulent abdomens, but no 
distinct enlargement of the spleen, rose spots, or diarrhoea. Perhaps there 
are no cases of enteric in the neighbourhood. Here diagnosis may be im- 
possible. We have never seen a fatal case of typhoid in an infant under two 
years of age, but such cases have been recorded. It is possible that some ot 



Enteric Fever 305 

these continued febrile attacks are due to some other form of bacillus. The 
bacillus coli communis has been suggested by some French authors ; they 
believe it may take on a malignant action. 

Acute Miliary Tuberculosis and enteric may be very similar, and for 
:a week or two the diagnosis may have to be held in abeyance. Careful 
temperature-taking every four hours will often greatly aid the diagnosis. In 
acute tuberculosis the fever is mostly intermittent, the diurnal ranges being 
perhaps 3 to 5 ; there are no true spots, rarely diarrhoea ; miliary tubercles 
may occasionally be detected in the choroid, crepitation may be heard in the 
lungs, or there may be some want of resonance at one apex ; the abdomen 
is not usually rounded. Tubercular Meningitis in the early stages may 
simulate enteric. A child who is seen for the first time, recovering from 
typhoid fever, being anaemic, wasted, and having perhaps some cough with 
rhonchi heard on examining the chest and possibly bedsores, might readily 
"be thought to be suffering from Chronic Tuberculosis. If there is diarrhoea 
-and abdominal tenderness, the two diseases at this stage may be still more 
alike. A careful examination of the lungs would generally distinguish 
between the two, as in chronic tuberculosis some consolidation at the apices or 
elsewhere would usually be found. Pyaemia may resemble enteric fever, 
especially in those cases where the pyaemia is secondary to some bone 
disease without any external wound. A case of pyaemia secondary to Pott's 
•disease of the spine, with abscesses in the lungs, which came under our care 
was thought for a few days to be enteric fever ; but the daily ranges of tem- 
perature are more extreme, the type more markedly intermittent in pyaemia 
than typhoid. A rounded distended abdomen, with a pimply rash, may cer- 
tainly occur in other diseases than enteric, though when true rose spots are 
present they are characteristic. 

Morbid Anatomy. — The solitary glands and Peyer's patches are swollen 
in catarrh of the bowel, enteritis, also in scarlet fever and septicaemia, as well 
as in enteric fever. Ulceration occurs in the later stages of enteritis, ileo- 
colitis, and tuberculosis, as well as in typhoid. In a typical case of typhoid 
there is usually no difficulty in making a post-mortem- diagnosis, as the 
swollen condition and ulceration of Peyer's patches, enlargement of the 
spleen and absence of tubercle are sufficiently characteristic. If death 
takes place early in the disease, there may be more difficulty. E berth's 
typhoid bacillus is with difficulty distinguished from other bacilli in the 
faeces, but if present in spleen pulp or juice, then its diagnostic value is much 
greater. 

Treatment. — The management rather than the medicinal treatment of 
typhoid fever is of the greatest importance. The patient must of course be 
put to bed in a cool room, and arrangements made for both night and day 
nursing ; it is needless to emphasise the importance of a trustworthy nurse 
at night to feed and attend to the patient's wants and soothe him to sleep. 
Sponging with warm water, to which some Condy's fluid or Sanitas has been 
added, should be performed every evening before settling the patient for the 
night, great care being taken to cleanse the buttocks and anal region, 
especially if the patient is suffering from diarrhoea, as the stools are apt to 
be smeared about. To keep the patient's back scrupulously clean is a matter 
►of importance in the prevention of bedsores. The patient's mouth must be 



306 The Specific Fevers 

carefully attended to, and cleansed by means of a paint brush or rag of 
decomposing food and foul secretions ; the more ill and insensible the- 
patient is, the more important does this become. Condy's Fluid or dilute- 
solution of boro-glyceride may be used lor the purpose. The diet should 
consist of milk diluted with barley water or soda water, and in amount should 
be suited to the age. During the pyrexial period milk is better taken than 
beef tea or other savoury foods, which as a matter of fact are quite unneces- 
sary. The more thirsty the patient is, the more must his milk be diluted, 
lest too much curd remain undigested in the stomach and intestines and give 
rise to flatulence and discomfort ; a pint and a half to a quart of milk daily 
will be sufficient. An excess may give rise to diarrhoea or accumulate in the 
large intestine as hardened faeces. In the later stages, when the tongue is 
cleaning, beef tea is usually taken well and forms a pleasant change of diet. 
Where milk does not agree, or when the diarrhoea is troublesome, peptonised 
milk or Bengers Food should be given. It is well to continue the fluid diet till 
a full week after the temperature has become normal. Our usual practice is 
to allow sops in the milk or beef tea on the thirtieth day, at once discontinu- 
ing it if the temperature rises. In mild or medium cases alcohol is unneces- 
sary. No medicine is required : a simple saline may be given. The treat- 
ment of hyperpyrexia must depend upon the effect which it has upon the 
patient, though in any case, if the temperature rises to 104 , sponging the 
head, trunk, and limbs with water at 6o° should be resorted to, or the cold 
pack maybe given, provided there is no immediate risk of peritonitis. If the 
temperature is not kept in check by these means, but the fever is not making- 
the patient drowsy or delirious, no other means need be taken, except perhaps- 
applying an ice bag to the head. Other means are however available, such as 
the administration of antifebrin or quinine, and the graduated bath. Antifebrin 
may be given in a large dose or in small doses of two or three grains,, 
frequently repeated, so as to keep the hyperpyrexia in check, rather than to- 
reduce it suddenly, as the latter result is attended by more or less collapse; 
in any case both antipyrin and antifebrin are apt to be depressing, and can 
only be safely used in the early stages, and not for too long a time together.. 
In the early stages, with due care, the graduated bath is useful in reducing 
temperature ; in the later stages it is contra-indicated, on account of the dis- 
turbance to the patient which it entails. The patient may be placed in the bath 
at a temperature of ioo°, and cold water added so as to reduce it to 7o°or 8o°, 
though it is rarely wise to allow the child to remain in longer than five 
minutes. Excessive diarrhoea should be checked by starch and opium 
enemata, or D overs powder by the mouth ; sleeplessness and delirium by 
a wet pack or small doses of nepenthe, the latter being more useful than 
bromides, chloral, or urethan ; abdominal pain or tenderness is best treated 
by nepenthe in free doses by the mouth, and opium fomentations, while the 
food and liquids taken are reduced to a minimum compatible with safety, 
pneumonia by stimulating applications such as mustard poultices or turpentine 
stupe, the latter being used with great care on account of the sores apt to be 
produced. Any signs of cardiac depression must be combated by alcohol in 
the form of mist, vini gallici, or champagne, or by caffeine, ammonia, ether, or 
digitalis. 

It is often an anxious question to decide as to whether a laxative should 



Enteric Fever 307 

be given when the bowels are constipated, inasmuch as a patient is rendered 
more comfortable by a free action of the bowels, and the distension and dis- 
comfort are lessened. On the other hand, one fears that the peristalsis set up 
by a purgative or even an enema may do irretrievable damage by converting 
an ulcer into a perforation or tearing down adhesions of lymph which have 
formed. At the same time it must be remembered that hard lumps of faeces 
irritate the bowel and fret and rub the ulcers, and in some of the worst instances 
of extensive ulcers in fatal cases we have found numerous hard lumps of 
faeces in the lower part of the ileum and large bowel. Some doses of castor 
oil during the first ten days are often beneficial if the bowels are confined ; 
after this time enemata are safer, though they are not free from risk, and should 
certainly be avoided if there are signs of peritonitis. If severe haemorrhage 
from the bowel occur, the greatest care must be taken to give the child only 
the smallest quantities of food by the mouth and to keep him as quiet as 
possible. An ice bag should be placed on the abdomen and a grain of ergotin 
given subcutaneously and repeated every two or three hours. Opium should 
be given in small doses if there is much restlessness. Turpentine or terebene 
in two or three drop doses in mucilage is useful as a stimulant and haemo- 
static. 

Can we abort enteric fever by giving laxatives or antiseptics ? This is a 
disputed point, inasmuch as enteric frequently aborts, especially in children, 
without the help of drugs, and the diagnosis in the early stage is difficult. 
We certainly believe that the danger of setting up perforation-peritonitis by 
giving purgatives has rather frightened us unnecessarily into the too sparing 
use of evacuant remedies such as calomel or castor oil. Small and repeated 
doses of calomel or castor oil during the first ten days may be safely given, 
and in many cases with great benefit. We are less inclined to the heroic 
doses of calomel advocated by some physicians. 

During convalescence dyspepsia and constipation are frequently trouble- 
some ; flatulence and a rise of temperature are very apt to follow any excess 
of starchy or any indigestible food, especially in early convalescence. The 
food should consist of meat essences, of broths, jellies, pounded meat, 
chicken, and fish, with small quantities of toast or stale bread. Good aherry 
with a grain or two of pepsine and some liquid malt extract, such as that of 
Allen and Hanbury's or Hoff's, are often very useful. The constipation is 
usually slow in disappearing ; purgatives should be avoided, as the constipa- 
tion is simply due to wasting of the muscular fibre of the bowel and weakened 
secretions. In this condition the mineral acids, strychnine, cascara sagrada 
and bitters are of most use. 

Typhus 

During an epidemic of typhus children suffer equally with adults, though 
the mortality is exceedingly small. It is probable that the fact that children 
usually suffer from the disease in a mild form, and hut few die, has given 
rise to the general belief that children are less susceptible to the typhus 
poison than are adults. That this is not the case has been shown con- 
clusively by Dr. Buchanan, who, after referring to the slightness of the fever 
in children, says : 'When inquiry .is to age is made to include ever) case of 



3o8 



The Specific Fevers 



attack, children and adults are found to be equally susceptible ; the actual 
incidence may even be observed to be strongly upon the young, partly 
because of their greater numbers and partly because adults are frequently 
protected by previous attacks.' That many children are attacked with 
typhus is shown by the statistics of Homerton Fever Hospital (given by 
Collie), for out of 711 admissions of typhus to the hospital during the period 
1 871-1880, 24 were under 5 years of age, 54 from 5 to 9 years, 113 were 
from 10 to 14 years of age ; it is more than probable that the proportion 
really attacked as compared with adults was much greater, but on account of 




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Fig. 47. — Temperature Chart of Typhus Fever, ending in recovery. Eliz. G., aged 7 years. 

the mildness of the fever they were nursed at home and not sent to hospital. 
Only two deaths took place among the 191 children under 14 years of age ad- 
mitted, while the total mortality was ten times greater, being nearly 20 per cent. 
Symptoms and Course. — The symptoms and course do not differ from 
those seen in adults, with the exception of their usually greater mildness. 
The attack commences with headache, pains in the limbs, drowsiness, more 
or less shivering, sometimes vomiting, rarely diarrhoea. This history closely 
resembles that often obtained in scarlet fever, and this should be borne in 
mind, as a hasty conclusion as to the nature of an attack may be a wrong 
one. If seen for the first time at the end of three or four davs, there is a 



Typhus 309 

listless expression on the face ; it is flushed, the eyes suffused, the conjunctivae 
injected ; the child may answer questions if spoken to sharply, but is drowsy, 
semi-delirious and irritable if interfered with. The tongue is dry, coated 
with a brown fur and protruded with difficulty, the lips are black, there 
are sordes on the teeth, while the gums easily bleed. An examination of the 
lungs reveals the presence of rhonchi, perhaps rales, and some loss of reso- 
nance at one or both bases. On the fourth or fifth day the rash usually 
appears ; the skin has a dusky congested appearance, with an indistinct 
mottling, in addition perhaps to petechial points, due to flea bites ; for our 
patients with typhus usually come from the dirtiest and most squalid quarters. 
Perhaps a dusky mottling is all that can be seen, but in more typical 
cases the rash is more definite, consisting of rose-coloured spots or maculae 
larger than typhoid spots, and with more ill-defined margins, scattered over 
the body. According to Collie they are first seen on the sub-clavicular 
regions, along the lower border of the pectoralis major, on the wrists, back of 
the hands and epigastrium. We have sometimes noted the rash especially 
well marked on the dependent parts of the body, sides of the thighs, and 
arms, and back, extending along the neck on to the cheeks, and present also 
on the dorsum of the feet. The temperature is usually continuously high, 
103 to 104 , the pulse small and weak, perhaps 120 to 130, and there is some 
cough, and frequently much delirium or wandering at night. The fever may 
last for the whole two weeks ; more frequently the symptoms undergo marked 
amelioration after the first week, and possibly the temperature declines to 
normal by the eighth or tenth day, all the symptoms becoming milder and the 
rash disappearing without becoming petechial, as it often does in adults. 
The rash may be only visible for a few days or may fade as the fever becomes 
less. While the above description applies to a typical case in a child, very 
severe ones may sometimes be met with, though far oftener the symptoms are 
decidedly milder. The tongue may never be brown, only coated with a white 
fur ; the rash may consist of a dusky mottling only ; there may be drowsiness 
without active delirium. The late Dr. Tomkins observed in some of his 
cases at Monsall Fever Hospital that there was marked torpor and lethargy 
during the first few days, so that the child was with difficulty aroused to 
take food. 

It is obviously important to recognise typhus, though the attack may be 
mild, as such cases are of course infectious and may spread the disease. 
Dr. Tomkins recorded the case of a woman who contracted a fatal attack 
by sleeping with ' a child suffering from mild typhus, the cause of the 
child's illness not having been recognised. 

Diagnosis. — The fact that typhus occurs in epidemics and is apt to prevail 
in the overcrowded and poverty-stricken quarters of a large city often helps 
the diagnosis ; but occasionally an epidemic breaks out in a school or in the 
homes of the well-to-do. The onset of the attack may suggest scarlet fever : 
the high fever, drowsiness, and dusky condition of skin present in a malig- 
nant case of the latter disease might render the diagnosis doubtful at first ; 
but the condition of the tonsils would usually clear up a doubt if the 
characteristic rash of scarlet fever was not present. Nevertheless we have 
seen a case fatal in two or three days that gave rise to some doubt, and in 
the absence of a post-mortem was never cleared up. The disease most likely 



310 The Specific Fevers 

to be mistaken for typhus is acute pneumonia (Collie) ; this is in accord with 
our own experience, as we have seen cases of acute ' cerebral pneumonia,' 
with physical signs delayed, sent into hospital as typhus ; the mistake is 
likely to occur, as in most cases of typhus some rales or rhonchi are to be 
heard. 

In 'cerebral pneumonia' the lesion is often at the apex of the lung ; if 
seen on or after the fourth day of illness, and there is bronchial breathing 
or dullness, or some high-pitched resonance over a portion of lung and no 
rash, the disease is almost certainly acute pneumonia. A dusky or mottled 
skin, brown dry tongue, rales or rhonchi scattered over the whole lungs or 
bases, would indicate typhus. Enteric fever may be mistaken for typhus, 
especially when acute, but the insidious nature of the onset, the absence 
of marked delirium or torpor, the tenderness on pressure over the abdomen, 
and the rose spots usually suffice to make a diagnosis. We have seen some 
cases of typhus where there was a good deal of general hyperesthesia and 
muscular tenderness, where pressure on the abdomen evoked expressions of 
pain. 

Prognosis. — This is mostly good, but fatal cases sometimes occur, the 
children succumbing in the first few days of the fever from the intensity of 
the poison. 

Treatment. — That of fever generally. Sponging with Cond^s Fluid should 
be resorted to daily ; the apartment should be large, airy, and warm ; stimu- 
lants are required in all but the mild cases ; milk and other liquid nourish- 
ment must be given in suitable quantities. Directly convalescence has set 
in a more liberal diet may be allowed. 

Varicella 

Varicella is a specific infectious disease closely resembling modified 
smallpox, though perfectly distinct from it. There are still a few who 
believe varicella to be a variety of smallpox, notwithstanding the many 
facts which point in a contrary direction ; these may be summed up as 
follows : the two diseases are not mutually protective — children who have 
recently had smallpox may contract varicella ; during epidemics of one 
disease the other is not unusually prevalent ; smallpox affects all ages, vari- 
cella affects children almost entirely; inoculation with the virus of smallpox 
produces smallpox, inoculation with the contents of the vesicles of varicella, 
when successful, produces only chicken-pox. 

Varicella occurs in epidemics in schools, workhouses, children's hospitals, 
and among the poorer classes of society where there are many children in 
constant contact with one another ; its epidemics, however, are not so wide- 
spread as those of measles or whooping cough, nor does it affect so large a 
proportion of the unprotected. It affects children almost entirely; thus in 
584 cases observed by Baader in Bale, 98 per cent, were under the age of 
ten years, and 65 per cent, below five years of age. Adults do, however, 
occasionally take it. We have several times seen nurses contract the disease 
from children suffering from it. 

Varicella can be communicated from the sick to the healthy by inocula- 
tion, by simple contact, or by infection being carried by a third person. 



Varicella 



311 



Trousseau failed in his attempt to inoculate ; Steiner seems to have been 
more successful, succeeding in eight cases out of ten. The disease is most 
usually communicated directly from children suffering from or convalescent 
from an attack ; it is also certain that the infection can be carried by means 
of a third person, and remain in an active condition in clothes for many weeks, 
inasmuch as sporadic cases of the disease will occur in hospital wards in 
patients who have been in for months, and where no cases had occurred 
previously in the ward for a long interval. 

Symptoms. — The incubation period in the inoculated cases reported by 
Steiner was eight days ; when contracted in the ordinary way it is usually 
about fourteen days, sometimes a day or two more. We have on several 
•occasions had an opportunity of verifying this. There are usually no fire- 
monitory symptoms ; the discovery of papules and vesicles on the body is 



111111 



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Fig. 48. — Temperature Charts of two cases of Chicken-pox in children of 
3^ years and 18 months. 

usually the first thing noted by the friends. In a few cases there is a diffuse 
redness of the body resembling the.roseolous rash which sometimes precedes 
smallpox, and which has given rise to the suspicion that the case is one of 
scarlet fever ; in one case a measly rash, preceding the vesicular eruption, 
made it look as if the child was suffering from both measles and varicella, 
but of this there was no confirmatory evidence. Frequent micturition was 
observed in one of our cases before the rash appeared. The premonitory 
fever if present is of short duration, varying from a few hours to twenty-four 
hours, and in this respect varicella presents a marked contrast to variola. 
The temperature is not as a rule characteristic, ami varies with the acuteness 
of the attack, mild cases with only a low vesicles being feverless, severe 
cases with a great number of vesicles being accompanied by a temperature 
of 104° or more. The most frequent type is the intermittent 'fig. 48), 



312 



The Specific Fevers 



The rise of temperature is accompanied by an accelerated pulse, coated 
tongue, and restlessness, though in mild cases these may be absent ; in 
a few hours rose spots, resembling the rash of typhoid, appear and quickly be- 
come vesicular. Probably at the time the first examination is made there 
will be both rose papules and minute blebs or vesicles containing clear fluid 
and surrounded by a zone of redness. By the next day a fresh crop of 
papules and vesicles will have appeared, the vesicles of the previous day are 
larger, perhaps some of them have aborted and commenced to dry up. 
Fresh crops appear on the third, fourth, fifth days, and perhaps later still, so 
that when the attack is at its height, as it usually is on the third or fourth- 
day, the trunk and extremities are thickly covered with vesicles and scabs.. 

probably also a few pustules where 
there has been some scratching and the 
vesicles have burst. The contents of 
the vesicles are at first quite clear ; as 
they enlarge their contents become 
more cloudy, but not purulent unless 
the vesicle has been injured and part of 
its contents has escaped. The vesicles 
are mostly unilocular, their upper sur- 
face is convex and collapses as soon as 
it is pricked, though in some cases a 
few vesicles may be seen more or less 
flattened, umbilicated, and multiloculaiv 
closely resembling smallpox or vaccina- 
tion vesicles. The number of vesicles 
varies greatly ; in some cases only a few 
are present, in others there may be 
many hundreds. They are never con- 
fluent. In the majority of cases the 
vesicles dry up and scabs are formed at 
their site ; these fall off in the course 
of a few days, leaving clear and healthy 
skin beneath. In some of the worse 
cases this is not so ; an ulcer, which 
may be some weeks in healing, forms 
beneath the scab and thus a scar is left 
not unlike those following severe small- 
pox. The vesicles make their appearance on the trunk, limbs, and scalp ; 
they are generally more sparely present on the face, tongue, and soft palate. 
The prognosis in varicella is uniformly good, as it is apparently never 
fatal in a previously healthy child. In weakly and tubercular children the 
varicella vesicles are apt to be followed by spreading ulcers, which, joining- 
one another and taking on an unhealthy action, sometimes assist in bringing: 
about a fatal result. Such cases have been described by Mr. Hutchinson 
under the name of varicella ^angrsenosa ; they are not uncommon in the 
out-patient room (see fig. 49). The gangrenous action is usually associated 
with tuberculosis, and it is curious that in all fatal cases of this affection— as 
has been remarked by Dr. J. F. Payne— tubercle has been found post mortem. 




Fig. 49.— Varicella Gangrenosa. Child aged 
2 years. From a photograph taken alter 
death. The patient died of tuberculosis ; 
she had had an attack of Varicella two 
months before death. 



Varicella 3 1 3 

Eustace Smith has known acute tuberculosis to follow varicella, and we have 
also seen several such cases. Nephritis is an occasional sequela, as first 
noted by Henoch. 

Diagnosis. — The disease with which chicken-pox is most likely to be. 
confounded is mild or modified smallpox, but as a rule no difficulty is ex- 
perienced. The points of most importance in making a diagnosis are the 
absence of premonitory symptoms and the character of the rash ; the fol- 
lowing table shows these : 

Varicella. Varioloid, or modified Smallpox. 

Incubation. — Thirteen to sixteen days. Twelve days. 

Pi emonitory Fever. — A few hours. Two or three days. 

Premonitory Symptoms. — Mostly nil. May include headache, backache, drowsi- 

ness, vomiting, delirium, convulsions. 
Rash. — Red spots becoming vesicular in a Red shot-like papules appearing on face, 
few hours and drying up in three or four wrists, body, limbs, and soft palate ; in 

days, leaving crusts ; coming out in crops the course of a day or two the papules. 

on four or five successive days on the becoming vesicles, and developing into 

scalp, trunk, limbs, face, and mucous pustules by the eighth day, or they may 

membranes. The vesicles are mostly dry up leaving only scabs, 

unilocular. 
Temperature. — Intermittent in character. Sudden rise, reaches its height when the 

papules are fully out ; then comes a 
speedy fall. The secondary fever is 
slight or absent in modified cases. 

Occasionally a vesicular syphilitic eruption may simulate varicella, though 
such eruptions are rare in congenital syphilis, and when present take the form 
of bullae of various size rather than vesicles. In one case which came under 
our notice, a vesicular syphilide closely resembled varicella, but there was no- 
fever, and some brown staining followed the rash. 

Qnaranti?ie. — How long does the infection last in varicella ? No case 
should be considered past the infection stage until all the scabs have cleared, 
away and the skin is quite smooth and normal. This is usually accomplished 
in three or four weeks. In one case which was admitted to hospital,, 
suffering from psoriasis, which had succeeded the eruption of chicken-pox,, 
and where some unhealed ulcers were present, the admission into the ward 
was followed by an outbreak of the disease some fortnight afterwards. The: 
child admitted had had chicken-pox five weeks before. 

Treatment. — Not much treatment is necessary. The child should be 
isolated, and preferably be kept in bed if there is a copious eruption. A 
light diet should be given, and ointment containing some tarry or carbolic 
compound will be useful to apply to the scabbing vesicles. 

Vaccinia. — Performance of Vaccination. — The safest age for vaccinating 
infants has been in dispute, some preferring to vaccinate within a few weeks 
of birth and before the monthly nurse leaves, while others much prefer post- 
poning the operation till three or even six months. Inasmuch as unvacci- 
nated children under one year if they contract smallpox almost certainly die, 
no time should be lost in vaccinating infants if there is any chance oi their 
being exposed to contagion— as, for instance, if smallpox exists in the house 
or is present in the neighbourhood in epidemic form. On the Other hand, it 
the risk of their being exposed to contagion is small, it is unwise to vaccinate 



314 The Specific Fevers 

•during the first few weeks of life, on account of the disturbance of the general 
health liable to follow ; infants of three months or six months old bear the 
operation better than infants a few days or weeks old. It is of importance 
to postpone vaccination beyond the end of the third month if the infant is 
not robust, or suffers from diarrhoea, malnutrition, eczema, intertrigo, or if 
erysipelas is prevailing in the neighbourhood. Revaccination should be 
performed at or before puberty. If human lymph cannot be obtained from 
.an infant of an undoubtedly healthy family, fresh calf lymph should be 
obtained, and if the latter is used, any objection to the performance of 
vaccination on the ground of transmitting syphilis and other diseases is 
•obviated. Calf lymph answers usually very well ; it is more viscid than 
humanised lymph, and consequently may fail to take unless care is taken to 
work it well in. The cuticle should be removed by a few scratches of a 
needle or lancet at the spot where a drop of lymph has been applied. After 
vaccination nothing is usually to be seen till about the third day, when there 
is some itching and a slight redness surrounding the spot, or there may be 
a tiny papule. By the seventh or eighth day there is a flattened vesicle at 
the seat of puncture, containing clear fluid in various loculi. During the 
next few days a red areola forms round the vesicle and its contents become 
cloudy ; by the tenth or eleventh day the fluid oozes out and forms a scab 
on the surface, which, becoming detached, leaves a superficial ulcer, which 
takes a variable time to heal ; a permanent cicatrix, which is circular, de- 
pressed, pale, and pitted, is left. The size and distinctness of the scar will 
depend upon the ulceration which has followed the pustule ; if the latter 
dries up without an ulcer forming, there will be hardly any scar left. There 
is often some febrile disturbance from the fifth to the tenth day. 

What are we to regard as the best vesicles for obtaining lymph from ? 
According to Dr. Hugh Thompson, 1 'they are such as, at the beginning of 
the eighth day (the day usually chosen for taking lymph, although not always 
the best), show the punctures made in vaccinating well healed with no 
scabbing, the vesicles depressed in the centre and elevated at the margin, 
containing a moderate amount of lymph, not acuminated ; that is, flat in 
proportion to breadth, and not having lost the inequalities, bosses and foveas 
— resulting from some of the connections between the epidermis and corium 
•still remaining intact, the areola incipient or only slightly developed. The 
lymph which exudes from them, on being pricked, is nearly if not quite 
limpid, somewhat viscid, moderate in quantity, and does not tend to run down 
the arm. 

' As a general rule it is the finest children — those, at least, who are such 
in the eyes of the vaccinator : " children of dark complexion, with a thick, 
clear, smooth skin," as Seaton remarks, indications of a strong vigorous 
constitution— who furnish the finest vesicles. At the same time care must 
be taken to see that the child is in perfect health, and especially, by a thorough 
■examination, that it is free of all skin diseases, and more particularly all 
indications of syphilis, among the most persistent and obvious of which 
(excepting, of course, manifest syphilides) are chronic coryza, generally from 
oirth ; a depressed nose, open fontanelles, hydrocephalic head, turgid veins 

1 'Inoculation for Smallpox,' by Hugh Thompson, M.D. ; Glasgow Medical Journal, 
-vol. xxvii. 



Vaccinia 3 1 5 

of scalp, tumid lymphatic glands. Many of the manifestations of syphilis 
disappear under treatment, and it is possible they may have thus disappeared 
without the disease being thoroughly eradicated ; but it is rare that one or 
more of the above may not be found if searched for. It is superfluous to 
caution against the smallest admixture of blood. 5 

Complications and Sequela. — These are fortunately few, though numerous 
.and important in the eyes of prejudiced persons, and a lengthy list could be 
easily compiled if all the evidence collected by such were to hold good. The 
most important are the following : (1) Syphilis (see infra) ; (2) Erythema 
and Erysipelas. There maybe an unusual amount of redness and hardness 
-surrounding the pustules, as a result of the lymph causing more irritation 
than it commonly does ; this may spread down the arm, and give rise to some 
glandular enlargement without there being any erysipelas present. Ery- 
sipelas does occasionally occur. The erysipelas coccus may gain entrance 
into the wound at the time of vaccination ; in this case symptoms will pro- 
bably arise within a few days, the incubation period being a few hours to two 
or three days. It is impossible to say for certain that it may not be longer. 
In a case which came under our notice the seat of the vaccine punctures 
began to become inflamed nineteen or twenty hours after vaccination. In 
such cases the vesicles and pustules often mature earlier than in normal cases, 
and a vesicle may be present on the second day, with more or less redness 
around the punctures. The patches of redness and oedema are migratory, 
as in other forms of erysipelas— that is, they do not necessarily remain in 
the immediate neighbourhood of the wound, but may affect the face, trunk, 
or any other part. The mortality of vaccine erysipelas is very high, most of 
the cases being fatal, death occurring in one to three weeks. It has un- 
fortunately happened that the vaccine has been taken from an infant suffer- 
ing from or incubating erysipelas, and has communicated erysipelas to infants 
vaccinated with it. Erysipelas may supervene at any period between 
vaccination and the healing of the pustules if the infant is exposed to 
the infection, the cocci becoming accidentally implanted into the wound. 
{3) Glandular enlargement. The axillary and cervical glands may enlarge 
and suppurate during the maturation of the pustules, or more commonly in the 
second week. We have seen several cases in infants with chronically enlarged 
.and caseating superficial cervical glands of the left side, which had commenced 
to enlarge shortly after vaccination, and it appears likely that in infants of a 
tubercular or 'strumous' tendency vaccination may be the exciting cause. 
Similar chronic axillary adenitis is also occasionally seen produced by 
vaccination, just as by any other irritation. (4) Cold abscesses and 
boils may form in various parts of the body, as they will at times after all 
suppurations, especially in tubercular or ' strumous ' children. (5) Various 
rashes occasionally make their appearance, mostly towards the end oi the 
week, when the vesicle is maturing. A roseolous rash over the body and 
arms, which is fugitive, disappearing mostly in twenty-four hours : a vesi- 
cular rash, consisting of a few pimples becoming vesicular ; a lichenous 
rash ; and patches of erythema may be sometimes present. We know ot 
no evidence which directly connects eczema with vaccination : it is ver) 
common during infancy in one form or another, ami it is not surprising that 
vaccination often gets the credit oi producing it. An impetigo is not 



3i6 



The Specific Fevers 



uncommon, having been produced by inoculation of the secretions from the 
pustules by means of the finger nails. 

Varioloid or Postvaccinal Smallpox. — Unvaccinated children suffer 
from smallpox in as violent a form as do unprotected adults ; indeed, accord- 
ing to Collie, ' smallpox is very fatal in unvaccinated children under five 
years of age, more than half dying, and nearly all infants under one year.' 

Children who have been vaccinated in infancy and take smallpox usually 
suffer from it in a modified form ; there may be no rash at all, or more often 
the attack aborts and the vesicles dry up without passing through the pus- 
tular stage, the secondary fever being absent or only slight. Sometimes 






iPillliii 









SSSSBSS 

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ilia 

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Fig. 50.— Temperature Chart of a case of modified Smallpox in a girl aged 10 years. 
Papular rash on the third day, becoming vesicular on the fifth. 

the attacks, according to Collie, are so slight that diagnosis is impossible, 
except from the fact that they occur after exposure to infection or in associa- 
tion with cases of undoubted smallpox. The premonitory symptoms may 
be present— headache, feverishness, backache— which disappear before the 
rash appears, the attack coming to an end without any papular eruption. It 
is much more common for the attack to abort immediately after the rash 
appears, secondary fever or pustulation being absent. The premonitory 
symptoms may be severe— headache, backache, the temperature rising to 103° 
or 104 on the third or fourth day, a copious eruption of papules appearing, 
perhaps being confluent on the face, to be followed by a sharp fall in the 
temperature of perhaps 4 or 5 . The papules become vesicular and dry up 
with but slight if any pustulation, and the child is convalescent at once. 



Varioloid 3 1 7 

The temperature chart (fig, 50) was that of a child aged ten years who 
was convalescent from scarlet fever, and who contracted smallpox while in 
the scarlet fever ward ; the only source of infection which could be traced 
was a visit of her mother twelve days before, the latter coming four miles 
from a district where smallpox was prevailing. There was marked head- 
ache but no pain in the back ; on the third day an erythematous rash was 
seen on the body, which suggested that her illness might be scarlet fever, 
though she had passed through a typical attack some weeks before ; on the 
afternoon of the same day a few tiny papules like the rose spots of typhoid 
were seen on the abdomen and arms, the headache was severe and the eyes 
suffused. The spleen was enlarged, being felt \\ inch below the ribs. On 
the fourth day the face, neck, 'trunk, and limbs were covered with well- 
defined papules, many confluent. The same evening the temperature fell 
from 104 to 97 . On the fifth day the eruption was copious, some of the 
papules were beginning to be vesicular ; the vesicles quickly began to dry 
up and scab, no true pustules appearing. The girl made a good recovery 
and was not permanently pitted. 

Diagnosis. — The fact that smallpox is at times a very mild disorder 
makes it important that it should not be overlooked, inasmuch as a mild case 
as well as a more severe one may be the means of spreading the disease. 
Diagnosis is hardly possible in the absence of a papular eruption, or the 
purpuric spots of the malignant form. 

Treatment. — The treatment is that of fevers generally. 

Whooping Cough 

Etiology, dr^c. — Whooping cough is an infectious disease which is 
characterised by a catarrh of the air passages and a peculiar spasmodic 
cough. It prevails in epidemics which are both widespread and prolonged, 
though sporadic cases are generally present in large centres of population. 
There is no disease which is more certainly infectious than whooping cough, 
in the sense that if those who are unprotected by a previous attack come in 
contact with those suffering from it they are almost certain to take it. If 
one member of a household is attacked, all the other members, both children 
and adults, who are unprotected, take the disease. If it enter a court or 
alley, it is tolerably certain that all the unprotected inhabitants will suffer. 
It is almost certain to spread in a similar way in a school or convalescent 
home. It is, however, a curious fact which we have often noticed, that 
whooping cough does not appear to spread to any great extent in hospital 
wards in which the children are in bed and the cubic space great the same 
fact has been noticed by Dr. Sturgesand Dr. Goodhart), and it would almost 
appear that close contact with the infected individual so as to inhale his 
breath was necessary to give the disease. It is impossible dogmatically 10 
deny that the poison of whooping cough can be conveyed on (he person or 
by clothes to a distance and so infect the healthy : but it is certainly excep- 
tional ; the common way in which it spreads is by direct contact with the 
sick. A very short contact is all that appears to be necessary -such, for in- 
stance, as a child meeting another for a moment in the street or in a shop : 
several instances of attacks contracted in this wav have come tinder oar 



3 1 8 The Specific Fevers 

notice. The epidemics, like those of measles, appear to occur in large 
cities every eighteen months or two years. It has been asserted that there 
is some definite relation between these two zymotics, as they frequently pre- 
vail epidemically together or one immediately preceding or following the 
other; it is very doubtful if this association is anything more than accidental, 
as they both are apt to recur every eighteen months or two years. The 
whooping cough epidemic lasts longer and more slowly reaches its height than 
the measles epidemic. Like measles, whooping cough seems to prevail at all 
seasons of the year; but, as one would naturally expect, it is more fatal in the 
colder months of the year than in the warmer months, in consequence of the 
broncho-pneumonia which is so apt to supervene if the child takes cold. 
The mortality is mostly high among very y^oung and weakly children, while 
in older children it is rarely fatal. During the decade 1 878-1 887, 3,669 cases 
of whooping cough were treated in connection with the children's dispensary, 
with 281 deaths, or a mortality of 7-6 per cent. Of these, 217 or 77 per cent. 
were under two years of age, 63 or 13 per cent, were from two to five years 
of age, and only one fatal case occurred in a child over five years of age. It 
is certain that these figures do not represent the total mortality, as they do 
not necessarily include those who die some months later of tuberculosis 
and gastro-intestinal atrophy. 

Incubation. — It is difficult to fix the latent period with precision, as the 
onset is gradual and the symptoms so often indefinite. It is usually seven to 
fourteen days before the child begins to cough, and another week or ten days 
before the characteristic 'whoop ' is heard. This makes an interval of two to 
three weeks between being infected and commencing to ' whoop.' 

Symptoms and Course. — The course of the disease is marked by three 
stages : (1) The catarrhal or premonitory stage ; (2) The convulsive or 
spasmodic stage ; (3) The stage of decline ox convalescence. These stages, it 
is needless to say, are not well marked, but one gradually succeeds the other, 
and this is especially true with regard to the third. 

The catarrhal stage begins with the symptoms of a feverish cold and 
tickling dry cough, which is not readily relieved by ordinary remedies. The 
cough is especially apt to recur at night, and it is remarked on by the friends 
as being more than usually troublesome, the child coughing and straining as 
if to relieve a persistent irritation in the throat. The cough keeps it awake 
at night, or it wakes up coughing and fails to get to sleep for some hours. 
During the day the child may appear well, or, on the other hand, the appetite 
fails and he looks pale and poorly. The cough, if not paroxysmal from the 
first, becomes so in the course of a few days, before the actual whoop is heard. 
There is usually some degree of fever at night, and dry rhonchus may often 
be heard on listening to the chest. The first stage may be complicated with 
bronchitis or pneumonia. In young children or infants the convulsive stage 
sometimes begins with a convulsion or series of convulsions. 

The Convulsive Stage. — The cough now comes not only in paroxysms, 
but there is a distinct whoop ; there are a number of short forcible expiratory 
efforts, as if an attempt was being made to expel some irritating matters, 
followed by the long-drawn characteristic inspiration which is technically 
called a ' hoop ' or ' whoop,' or in some parts of the country a ' chink.' It is 
perhaps hardly right, at any rate when the second stage is well established, 



Whooping Cough 3 1 9 

to speak of the expiratory coughs as 'efforts;' the child, prompted by a 
peculiar tickling sensation in the throat, attempts to relieve it by coughing, 
but in a moment the coughing goes on in spite of any voluntary effort to 
repress it, so that the child's face becomes congested and the facial veins 
distended, before the inspiratory act takes place, and the air rushes into the 
air-passages and lungs through the narrowed glottis. Fit after fit of cough- 
ing will often follow one another, till the child vomits or a rush of stringy 
mucus, perhaps streaked with blood, pours out of its mouth and nose. 
In the worst cases the distress occasioned by these fits of coughing 
is extreme, and the child dreads their recurrence, not only on account of 
their discomfort, but from the aches and pains it suffers, by reason of 
the over-strained and weary respiratory muscles. To a weakly child the 
disease is necessarily a formidable one ; the exhaustion produced by the 
constant muscular efforts, the frequent vomiting which prevents a proper 
amount of food from being assimilated, together with the intestinal catarrh 
which in a greater or less degree accompanies it, often reduce the child to a 
feeble and emaciated condition. It can easily be imagined that forty or 
fifty attacks of coughing every twenty-four hours produce great muscular 
exhaustion, and affect the child's vital powers. In milder cases, where the 
fits of coughing do not exceed twelve, the child may appear quite well 
between the paroxysms, and, though perhaps vomiting after the cough, it is 
quickly ready for another meal, with sharpened appetite. Fever is mostly 
present in the second stage in variable degree, especially at night. An 
examination of the chest will generally disclose bubbling rales in the larger 
tubes, the secretion being freer than in the first stage. 

The Stage of Decline. — After a variable period of four to six weeks, during 
the latter portion of which the attacks of coughing have been diminishing, 
the characteristic whoop disappears, and convalescence may be said to be 
established. Mostly the paroxysmal character of the cough remains, and 
often the vomiting ; gradually the bronchial catarrh disappears, and the 
cough ceases, though it is very likely to return, and the whoop along with it, 
whenever fresh cold is taken. 

Complications. — By far the commonest is some form of broncho- 
pneumonia ; pleurisy and empyema are not unfrequent. There is nothing 
specially characteristic about the broncho-pneumonia of whooping cough ; it 
is usually double, is very apt to be generalised rather than 'patchy.* and 
tends to resolve, slowly passing into a subacute or chronic state. Croupous 
pneumonia is not uncommon in older children who take a chill during con- 
valescence, and may be followed by empyema. Empyema and atelectasis 
are very apt to occur in connection with bronchitis in small and rickety 
children. Young children arc sometimes convulsed, the convulsions being 
due to asphyxia, and perhaps meningeal haemorrhage ; drowsiness and 
coma are usually due to the same causes. We have seen a temporary 
hemiparesis arise during whooping cough. Cerebral symptoms, whether 
convulsions or drowsiness, are o( grave import. Intestinal catarrh and 
diarrhoea of a mucous character are also common : the catarrhal condition 
of the air passages extends to the intestines, and large quantities of mucus 
are secreted, which prevent the digestion and assimilation of food and cause 
a rapid passage o( the food through the intestines. The child passes small 



320 The Specific Fevers 

mucoid stools many times a day, is feverish and rapidly wastes. Sometimes 
the diarrhoea is of a dysenteric character. Tuberculosis, especially of the 
bronchial and intestinal glands, is a sequela rather than a complication, and 
usually follows some months later. A wasting during the third stage is 
oftener due to intestinal catarrh or chronic broncho-pneumonia than to 
tuberculosis. Among the lesser complications are ulceration of the fraenum 
linguae, stomatitis, and sores about the nose and lips. Small conjunctival 
haemorrhages are very common. The child often remains for a long time in 
a weakly s-tate of health, and may take long to regain its former strength. 
Permanent deformity of the chest may remain as a legacy left by an attack 
of whooping cough. 

Diagnosis. — Often no diagnosis can be made in the early stages, and this 
is the more unfortunate as there can be no doubt that the disease is infectious 
during this stage. The fact that whooping cough occurs in epidemics will 
often aid us in coming to a conclusion. Difficulty may often arise in more 
chronic cases in which there is a paroxysmal cough followed by more or less 
of a stridulous sound, as to whether such are specific and are to go into 
quarantine. The diagnosis will turn largely on whether any cause for the 
spasmodic cough can be discovered as well as on the history ; if there has been 
previous wasting, and there is some evidence of tuberculosis of the lungs, 
enlarged mediastinal glands would be suspected as the cause of the spas- 
modic cough. Diagnosis is often difficult in infants, as also it sometimes is 
in older children, who may have whooping cough without any characteristic 
* whoop ; ' the 'whoop' may also cease when pneumonia supervenes. 

Prognosis. — The fact that the mortality is vastly greater in cnildren 
under two or three years of age than it is in older children must be borne in 
mind in forming a forecast of results. The prognosis in the case of an infant 
or a weakly child of eighteen months or two years of age is very uncertain, 
and death may occur suddenly during a fit of coughing from convulsions 
or spasm of the glottis. The prognosis is always rendered grave by the 
presence of broncho-pneumonia ; the latter when it follows whooping cough 
is more fatal than when non-specific. Whooping cough during the winter 
months is always more likely to be complicated with chest disease than in 
the summer ; and while this is especially true of the poorer classes, it holds 
good also to a lesser extent in the better housed classes of the population. 
The presence of rickets affects the prognosis unfavourably. The diagnosis 
between chronic broncho-pneumonia and tuberculosis and between chronic 
intestinal catarrh and mesenteric disease is very difficult, but the tubercular 
diseases are much more likely to follow at a distance with a period of com- 
parative health intervening, while the simpler forms are more likely to 
complicate or immediately follow. A chronic pneumonia often clears up, 
and the child recovers, and a subacute intestinal catarrh may not improbably 
do the same. 

Quarantine. — Six weeks is usually stated as the time the infection lasts, 
dating from the commencement of the whoop ; but in all cases it is wise to 
keep up the quarantine till all cough has ceased and the child is quite well. 
If the cough or even whoop recur after a period of undoubted health, there 
is no fear of infection. 

Pathology and Morbid Anatomy. — The epidemic prevalence of whooping 



Whooping Cough 321 

cough and its infectious character would suggest its cause being due to 
some micro-organism. Letzerich and others have described such micro- 
organisms in the sputum of patients suffering from whooping cough ; but it is 
doubtful if the actual specific bacillus has been isolated from the numerous 
micro-organisms found in the secretions of the mouth and fauces. From 
the observations of Von Herfif and others who have watched the larynx with 
a laryngoscope during a paroxysm of coughing, it would appear that a 
small flake of mucus secreted from the posterior wall of the larynx was the 
excitant of the spasm. The entire larynx and trachea was in a condition 
of catarrh, the greatest irritability being in the inter-arytenoid region and the 
under part of the glottis. Some believe that the nasal mucous membrane 
rather than the lower respiratory tract is the seat of irritation, and that it is 
here that local remedies should be applied. 

No characteristic appearances are found on the post-mortem table ; the 
lesions found will vary according to the mode of death. The brain is 
usually congested, especially the veins ; there is often some subarachnoid 
fluid on the convexity and much fluid in the lateral ventricles. Various 
lesions may be found in the lungs, such as injection of the mucous mem- 
brane of the larynx and bronchi, with excessive secretion, emphysema, 
collapse, and various stages of broncho-pneumonia. 

Treatment. — The most important part of treatment consists in confining 
the patients to well-aired rooms which are free from draughts and maintained 
at an equable temperature. Two large rooms should, if possible, be set 
apart for the treatment, the one occupied being maintained at a temperature 
of 6o°, while the other is being thoroughly aired or disinfected, the latter 
being again warmed before the patients are removed. There can be no doubt 
that the attack is rendered more intense and protracted by rebreathing the 
infection as well as by a fresh catarrh being set up. Except in the warmest 
weather, the patient should be confined to his rooms in the house the whole 
time the disease lasts, as long as any ' whooping ' is present, and as long as 
any rales or rhonchi are heard in the chest. Too great care cannot be 
exercised here ; the bronchial tubes and lungs remain exceedingly sensitive 
to cold, and many severe attacks of pleuro-pneumonia have resulted both in 
old and young from a chill caught at outdoor games or from having gone to 
the seaside for change of air. Children are much better at home until 
well over the attack, not only for the sake of others but for themselves ; and 
the pleadings of the friends for change of air must be sternly resisted until 
six weeks at least from the commencement of whooping. With regard 
to medicinal treatment, there is no lack of remedies which have been 
tried, and no disease has been more ineffectually though diligently chugged. 
It is quite safe to say that no specific has as yet been discovered. During 
the catarrhal stage, when the cough is hard, the expectoration scant)-, and 
there is fever, the best remedies include small doses of antimony, ipecacuanha. 
liq. amnion, acetatis, or nitrate of potash. At night when the cough is 
especially troublesome hot mustard poultices should be applied to the chest. 
and hot demulcent drinks, such as black currant tea, or barley water, or 
lemonade may be taken. Beef tea is often of service for the night, and 
a dose of hot brandy-and-water will sometimes induce sleep. The room 
should be kept moist with hot steam if there is much bronchial catarrh 

V 



322 The Specific Fevers 

or laryngitis. In the spasmodic stage, when the secretion is free, the ex- 
pectorants should be stopped, and sedatives and small doses of narcotics 
substituted. At this stage the diffusion of carbolic acid vapour through 
the apartment is frequently of great service ; this may be done by vaporis- 
ing strong carbolic powder in one of Calvert's carbolic vaporisers ; it is 
not certain how this acts ; no doubt to some extent it soothes by acting as 
an anaesthetic to the fauces. In a similar way cocaine or resorcin may be 
used in the form of a spray or mopped on to the fauces with a brush, but the 
effect is usually only temporary, as the anaesthesia produced by cocaine is 
too short to be of much service. Internally we are inclined to believe that 
antipyrin, antifebrin, and phenacetin are among the most useful remedies ; 
from two to eight grains of the former being given every four hours according 
to age, and half this dose of the last two. Of other drugs at this period, 
belladonna, chloral, bromides, opium, cannabis indica, quinine, take the first 
place, but all at times fail to give any appreciable relief. Tr. belladonnas is 
best given in small doses every four or six hours, increasing the frequency 
rather than the size of the dose. The combination of belladonna and 
cannabis indica is a favourite one ; they may be combined as in F. 28. 

The bromides and quinine dissolved in syrup of lemons with syrup of 
Santa Yerba is also a good combination. Croton chloral is highly praised 
by Dr. Webb ; he orders a drachm of this drug to be dissolved in two ounces 
each of tr. cardamomi and glycerine, giving half a teaspoonful to two tea- 
spoonfuls every four hours to children of one to ten years. Dr. Ringer 
advises tr. lobeliae, and gives doses of five to ten minims every hour even to 
young children. Opium is of all drugs the most certain to relieve ; but it is 
perhaps best reserved to be given in one dose at night ; one to five drops 
of nepenthe or half to two grains of Dover's powder will often secure a fairly 
good night. The bowels should be carefully attended to, and a laxative will 
frequently be required. Unless the secretion is very copious, poultices or 
fomentations in this stage give more relief than do liniments. 

In the later stages, when the secretion is copious and the cough less and 
less spasmodic in character, nitric acid, alum, quinine, are most likely to be 
of service. Alum may be given with some sedative as conium or hyoscyamus, 
the old formula of Golding-Bird's being a good one : Alum. gr. j, succi 
conii it\v, syrup, rhceados 1T(x, aq. anethi ad 5j \ 5j every four hours. 
Of external applications there are a goodly number which have been em- 
ployed with varying success. Equal parts of lin. camph. co., lin. saponis, 
and lin. belladonnae, used cautiously to tender skins, make a good stimu- 
lating liniment. Some have great faith in oil of amber, as in the following : 
Ol. succini 5\j> tr. opii 5ij, sp. camph. 5SS, ol. amygdalae 3SS. The liniment 
of iodide of potassium and soap is useful. The diet both in the spasmodic 
and catarrhal stage should be carefully arranged, and is difficult on account 
of the vomiting so frequently present. It will often be necessary to feed little 
and often to make up for food vomited. The complications, such as broncho- 
pneumonia and intestinal catarrh, must be treated on the general principles 
given elsewhere. 

Mumps, Parotitis. — Mumps is an infectious disease which is apt to 
prevail in epidemics ; sometimes these extend over wide areas, though at 
other times cases occur and there is little tendency to spread. We have 



Mumps, Parotitis 323 

never noticed an extensive epidemic in hospital, but the nurses are apt to 
catch the disease from children who have been admitted incubating mumps, 
and it would seem that close contact, perhaps inhaling the affected person's 
breath, was the commonest way in which an attack was contracted. It 
sometimes happens that there is no spread of the disease in the ward where 
the affected child was, but cases have occurred in other wards, the infection 
being carried by a nurse, or perhaps by a nurse who has herself had a slight 
.attack. 

Incubation. — According to Dr. Dukes, fourteen to twenty-five days. In 
some cases observed by us, it was fourteen, seventeen, and twenty-one days 
respectively. 

Sympto7iis and Course. — Mumps is usually a mild disease attended by 
discomfort rather than serious illness. The attack usually begins with chilli- 
ness, stiffness about the jaws, local tenderness, often neuralgic pains ; there 
is often no fever, sometimes the temperature goes up suddenly to 102 or 
103 . The swelling is at first one-sided, involving the region of the parotid, 
which is prominent and tender ; deglutition is difficult and painful. Both 
sides are usually swollen in a day or two, and the patient presents a cha- 
racteristic appearance. The fauces and tonsils are normal. While the 
parotids are usually affected, in some cases the swelling is entirely confined 
to the sub-maxillary salivary glands on one or both sides ; it is in these 
cases that the nature of the attack is likely to be overlooked. The attack 
lasts, as a rule, from a few days to a week. Orchitis occasionally occurs in 
boys about puberty. Hemiplegia has been known to follow (Gowers). 

Diagnosis. — We have known cases of mumps sent into a scarlet fever 
ward as cases of scarlet fever, and we have also seen a case of tonsillitis with 
enlarged cervical glands, probably scarlatinal, which was diagnosed as mumps. 
In all cases of doubt as to the nature of the external swelling, the appearances 
presented by the tonsils should be decisive. The swelling due to mumps in 
the majority of cases corresponds to the parotid region, the swelling of 
cervical glands secondary to tonsillar affections is at the angle of the jau 
or just behind it. There is rarely much fever or illness with mumps; in 
diphtheria or scarlet fever, where there is much external swelling or cellulitis, 
the child is evidently gravely ill, and if a satisfactory view of the fauces can 
be obtained, they will be seen to be swollen, cedematous, and perhaps covered 
with exudation. In adenitis, attended by fever, it is the lymphatic glands 
rather than the parotid which are affected. In spite, however, of these dis 
tinctions, difficult and doubtful cases may occur. 1 

Treatment. — Not much is required except hot fomentations or belladonna 
liniment to the parotid regions, and a saline followed by a tonic. Three 01 
four weeks, according to the severity of the case, should elapse before the 
patient returns to school or mixes with his fellows. 

Malarial Fever. — Children who live in malarial districts suffer fron 
malarial attacks as frequently as do adults ; indeed, according to Holt, the] 
are peculiarly susceptible. In this country many opportunities do not occui 
of seeing the disease in its early stages ; the cases which mostly coiru 
under observation are those which are chronic ; having acquired the disease 

1 Suppuration in a parotid gland may take place in enteric or pyaemia, but th - cat 
hardly be mistaken for mumps. 



324 The Specific Fevers 

abroad and having been invalided home. In these cases marked anaemia 
with enlarged spleen, and perhaps intermittent fever, form the commonest 
symptoms. The anaemia is frequently profound and the spleen attains to 
an enormous size. Nephritis as a sequela of aguish attacks is sometimes 
seen in this country. Such a case we saw with Dr. Massiah, the attack 
having been contracted in Brazil ; there was marked anaemia, enlarged 
spleen, the urine was highly albuminous, and contained fatty and fibrinous 
casts. According to Lewis Smith, intermittent fever when it affects those 
over 3^ years differs little from the adult form, while below that age it presents 
some peculiarities. Malarial fever may be hereditary, being derived from 
the mother. In one case, recorded by Lewis Smith, an infant showed dis- 
tinct symptoms a week after birth ; the mother had suffered from tertian 
ague at intervals during the two years prior to her confinement. In the 
infant the type is quotidian, rarely tertian ; there are three stages presented 
by an attack ; the second or febrile is well marked, the temperature rising to 
104 to 106 ; the first and third less so. The spleen soon enlarges, and 
after a week or two, if the attack continues, there is marked anaemia. The 
enlargement of the spleen fails to take place in some of the cases. Dr. 
Emmett Holt, of New York, in making an analysis of the symptoms of 184 
cases of malaria in children, has pointed out how much more insidious the 
invasion of the disease is in children than in adults, and consequently there 
is more liability to Overlook it and attribute the symptoms to other causes. 
Even the periodicity of the recurrence may not be regular, which would 
still more throw the physician off his guard. In his cases with a gradual 
invasion he noted anaemia, frontal headache, constipated bowels, muscular 
weakness, vomiting, furred tongue, drowsiness, and epigastric pains ; these 
symptoms usually recurring in the afternoon. The spleen was enlarged, but 
there were exceptions to this. The fever noticed by this author assumed three 
types : the first in which the fever remained high for twenty-four to seventy- 
two hours, when a marked remission took place, the temperature then assum- 
ing a remittent type ; secondly, the fever is at first slight and only present 
at one period of the twenty-four hours, but gradually increases in intensity 
and assumes a remittent type ; thirdly, assuming a distinctly remittent 
or intermittent type from the outset. Cerebral symptoms are common ; 
there are frontal headache, drowsiness, and apathy, occasionally 4 convul- 
sions ; pains in various parts of the body ; various spasmodic disorders, 
as torticollis and motor paralysis, are less common, but sometimes take the 
form of paraplegia. Dr. Holt has also pointed out that the malarial poison 
may complicate and modify other diseases ; of these bronchitis and pul- 
monary congestion are common, the latter closely resembling pneumonia in 
the onset, but subsiding in a few hours, to come on again in the course of 
twenty-four hours. Spasmodic asthma of malarial origin may occur. Various 
gastro-intestinal disorders, as vomiting and diarrhoea, occur periodically at a 
certain time daily. The diagnosis in these cases depends Upon : (1) Perio- 
dicity of the symptoms ; (2) the co-existence of splenic enlargement ; 
(3) failure of the usual remedies to relieve ; (4) their prompt disappearance 
under the use of antiperiodics. 

Treatme?it. — The treatment consists, as in adults, in the administration of 
antiperiodics, such as quinine, cinchonine, and arsenic. 



325 



CHAPTER XIV 

DISEASES OF THE CIRCULATORY SYSTEM 

Diseases of the Heart 

Physical Examination. — An examination of the heart includes an en- 
deavour to determine its position, size, and the character of the cardiac 
sounds. It is needless to say that the younger the child, the more difficult 
it is to make a satisfactory examination. The first point to determine is the 
position of the apex beat, and as this gives us important information for 
making a diagnosis, it should never be neglected. If not visible its position 
may usually be felt by laying the extended hand on the cardiac area, and 
note must be made as to whether it occupies a larger space than normal, and 
whether it is accompanied by a thrill. The usual position of the cardiac 
impulse in adults is in the fifth interspace and well within the left nipple line. 
Symington has shown, by a number of frozen sections of the thorax at dif- 
ferent ages, that during childhood the apex beat is apt to take a more 
^external position as regards the nipple than in later years, a result due to 
the greater relative narrowness of the child's chest in the transverse 
diameter. As a matter of fact, it is usually well within the nipple in most 
children according to our observations, but we must not hastily come to the 
conclusion that because we may find in a given case it is actually in a line 
with the nipple that disease is present. If external in position to the nipple 
we should always be suspicious that there is an abnormal displacement of 
the heart to the left, or there is some dilatation of the left ventricle. 1 If the 
impulse is raised it would suggest that it was displaced upwards by a dis- 
tended stomach or other abdominal enlargement, or there is chronic lung 
disease of the left apex, or possibly pericardial effusion. If the impulse is 
displaced to the right there is in all probability fluid in the left pleura. 
Epigastric pulsation in a case of chronic heart disease generally means 
dilatation of the right ventricle. A heaving impulse lower than normal, the 
chest wall being lifted during systole, suggests hypertrophy of the left 
ventricle, a diffused weak impulse implies dilatation. 

In mapping out the size and position of the heart by means of percussion 
we necessarily take the 'deep dullness ' as our guide, but as the cardiac 
dullness shades away laterally into the pulmonary resonance, great care 
must be taken in the determination. Let us bear in mind that the shape 
and elasticity of the chest walls may modify the percussion note, and this is 

1 StefFen comes to the conclusion that in most children the cardiac impulse is 
nipple line, and in some instances one cm. external, without indicating disease. 



326 Diseases of the Circulatory System 

especially true in percussing over the lower half of the sternum. Some writers 
have laid down rules as to the limits of the cardiac dullness in children of 
various ages. We doubt very much the correctness of some of the statements 
which have been made, and we should recommend the student to bear in 
mind only the limits which he has been accustomed to observe in the wards 
of an adult hospital, but not forgetting that an extension of dullness to the left 
more than in the case of adults does not necessarily mean a pathological con- 
dition. The upper limit of the heart is the upper edge of the third left costal 
cartilage ; dullness extending higher than this suggests fluid in the pericardium,, 
an enlarged heart, or a lesion at the left apex of the lung. The left border of 
the heart should lie within a curved line drawn from the junction of the third 
left costal cartilage with the sternum, extending downwards and to the left to- 
the fifth space just within the nipple line. The right border corresponding 
to the right auricle should lie within a line drawn from the above point 
curving downwards and outwards along the right edge of the sternum. 
Inferiorly the cardiac dullness cannot be distinguished from the hepatic dull- 
ness. In chronic disease the chest wall is frequently bulged over the cardiac 
area, while the dull area is extended both to the left and right, and may even 
measure as much as 6 inches across from side to side. We will defer 
reference to the cardiac sounds till later. 



Congenital Heart Disease 

The different forms of malformed hearts are exceedingly numerous and 
defy any attempt at classification, but as many of these, though of great 
interest to the anatomist as illustrating the various stages of development, 
are of little practical importance to the clinician, no detailed description is 
needed here. The principal causes at work in producing these malformations 
may be classified as follows : (1) Persistence of foetal openings, more par- 
ticularly the foramen ovale, in consequence of the lungs remaining in part in 
the foetal state after birth ; there is obstruction through the lungs and over- 
filling of the right heart. (2] Endocarditis, occurring during foetal life, 
affecting the pulmonary, the tricuspid, and less often the aortic or mitral 
valves, producing stenosis at the valvular orifice, and as a secondary effect 
the persistence of the foramen ovale, or ductus arteriosus ; or the septum 
ventriculorum may remain incomplete. (3) An arrest of development at 
some period of foetal life or the results of a false step, as it were, as when 
a transposition of the aorta and pulmonary artery occurs. 

Congenital heart disease not infrequently occurs in several members of 
the same family ; in one case coming under our notice, where there were four 
children two sisters and one brother were thus affected. 

Symptoms. — Cyanosis and the presence of a bruit are the only reliable 
signs of congenital heart disease. Cyanosis is mostly, but not universally, 
present, and it varies considerably in intensity. It is most marked, and is 
sometimes only present, when the infant cries, the face being dusky, the lips 
and tongue and extremities becoming of a bluish tinge. We must, however, 
bear in mind that some cyanosis may be present in prematurely born infants 
when the lungs are but partially inflated, and remain in the foetal state, and 
often atrophic and feeble infants have blue and cold hands and feet. If, 



Congenital Heart Disease 327 

however, the cyanosis persists for many weeks, it is probably due to mal- 
formation of the heart. In a certain proportion of cases murmurs are heard. 
These are apt to be of a rough, rasping, superficial character, and the rhythm 
is often exceedingly difficult to determine, on account of the rapid action of 
the infant's heart. The differential diagnosis is very frequently impossible, 
and only a sort of guess can be made. The position of greatest intensity 
should be determined ; but this is not always easy, as many of the murmurs 
are so loud that they are heard all over the chest. Note should be taken as 
to whether the bruit replaces or is only heard through, as it were, the heart 
sounds. A thorough examination cannot, perhaps, be made at first, as it is 
unwise to expose a weakly infant too much, and, moreover, the possibility of 
a pericardial friction sound in newly born infants must not be forgotten. 
Any external congenital malformation would suggest that the heart defect 
was the result of some arrest of development or some abnormal development 
rather than due to endocarditis. 

The prognosis is, of course, bad, but much uncertainty must necessarily 
exist, as the diagnosis of the exact form of lesion present often cannot be 
made. The more cyanosis present the worse is the prognosis, as, in infants 
at least, there is a great liability to meningeal haemorrhage taking place, 
either slowly or during a fit of crying, vomiting, or coughing. Convulsions 
may at any time supervene and quickly prove fatal. The venous state of 
the blood interferes with the secretion of the digestive juices, and the whole 
system is worked at a disadvantage. In older children the amount of hyper- 
trophy and dilatation must be taken into account in making a prognosis ; the 
larger the heart, the nearer is it to the end of its tether. The extent to which 
clubbing of the fingers is present must also be considered. 

Patent Foramen Ovale. — The foramen ovale allows of the passage of 
blood from the right to the left auricle during fcetal life (see fig. 51), but closes 
up shortly after birth if there is no obstruction to the circulation of blood 
in the pulmonary system, and consequent increased blood pressure on the 
right side of the heart. If, on the other hand, the lungs are only partially ex- 
panded, remaining in part in the fcetal condition, a portion of the blood which 
under normal conditions would enter the pulmonary circulation escapes it by 
passing directly from the right heart to the left through the foramen ovale. 
Repeated attacks of bronchitis after birth may have a similar effect in pre- 
venting the closure of the foramen ovale. The further history of such cases 
is uncertain, but there is reason to suppose that, if the child remains free 
from pulmonary trouble, the foramen ovale may close, or at least allow of 
but little mixture of the blood of the auricles, and be therefore of but slight 
detriment to the patient. It is not uncommon to meet with such cases in 
children a year or two old, who come under medical treatment for bronchitis, 
and in whom a loud systolic basic bruit is heard, which varies in intensity 
according to the amount of pulmonary trouble present. In one oi our own 
cases, a child of thirteen months, there was much bronchitis, anaemia, and 
oedema ; the child recovered for a while, but died of diphtheria nine months 
later. The post-mortem showed the foramen ovale to be the size o( a 
shilling, partly closed by membranous bands crossing it ; possibly these had 
produced the bruit heard during life. The pulmonary artery was dilated. 
An open foramen ovale is usually present in eases where there is Stenos 



328 



Diseases of the Circulatory System 



the pulmonary artery or tricuspid orifice. The murmur produced by the 
passage of blood through an unclosed foramen ovale is heard best at the base 
of the heart in front, and is also heard well behind. In position the foramen 
lies at the posterior aspect of the heart, on a level with the fifth costal carti- 



Pulmonary Artery 

R. Auricle 



Umbilical Vein" 




L. Auricle 



Aorta 

Ductus Venosus 



— Portal Vein 



L. Iliac Artery 
R. Iliac Artery 
Internal Iliac 



External Iliac 



Placenta 
Fig. 51.— Plan of Fcetal Circulation (Gray's 'Anatomy'). 



lage, where it joins the sternum, being behind the sternum and somewhat to 
the right. Posteriorly it lies just in front of the seventh vertebra. There may 
be an open foramen and yet no bruit be heard, as, if there is no pulmonary 
obstruction, there may be little or no rush of blood through the orifice. As 
the passage of blood from auricle to auricle takes place during the auricular 



Congenital Heart Disease 329 

systole, presumably the bruit should be 'presystolic' in rhythm, immediately 
preceding the first cardiac sound. It can readily be understood that it is not 
easy to distinguish between a presystolic and systolic bruit in an infant or 
young child, especially if there is some pulmonary trouble. 

It is not uncommon to find a more or less open foramen ovale in older 
•children. In one of our cases, a boy of ten and a half years who suffered 
from chronic heart disease and had had several attacks of rheumatism, we 
found post mortem a large dilated heart with a much thickened pericardium, 
an abnormally small aorta only admitting a little finger, an open foramen 
ovale, and a thickened and puckered mitral valve. 

Patent Septum Ventriculorum. — Unlike the inter-auricular partition, 
the septum between the ventricles becomes complete during fcetal life, usually 
during the third month. If, however, there is any obstruction at the pul- 
monary orifice, or any malformation which renders unequal the pressure of 
blood in the two ventricles, the ventricular septum remains incomplete and 
allows of the passage of blood from one ventricle to the other. The spot 
which remains open, or is the last to close up, is the so-called 'undefended spot' 
at the base, where the septum intervenes between the mitral and tricuspid 
valves, and is normally the thinnest and most membranous. An incomplete 
septum is usually associated with pulmonary obstruction, or is found in 
cases where the aorta arises from both ventricles, or where there is trans- 
position of the great vessels. In some few cases it appears to be a primary 
defect arising from arrest of development or some unknown cause. In such 
cases the child may live several years, the heart becoming enlarged, more 
particularly on account of the left ventricle undergoing dilatation and hyper- 
trophy in its efforts to maintain sufficient tension in the arteries during the 
systole, while under the disadvantage of its contents being in part forced into 
the more feebly acting right ventricle. The murmur produced is loud and 
rough, replacing the first sound ; it is heard loudest over the lower part of 
the sternum, but is well conducted to the seat of cardiac impulse. It is also, 
if loud, heard both in the axilla and posteriorly. 1 

Stenosis of the Pulmonary and Tricuspid Orifices. — If an endocarditis 
occur durjng fcetal life, especially during the early period, it is apt to affect 
the pulmonary and tricuspid valves, the liability of the valves on the left side 
being greater towards the end of fcetal life, as more and more work is imposed 
upon the left heart. In some cases a complete stenosis of the pulmonary 
and tricuspid orifices takes place, the heart becoming trilocular. Thus in the 
case of an infant, markedly cyanotic during life, but who lived for four 
months, it was found that the pulmonary orifice was completely closed, the 
tricuspid only admitted a crowquill, and the right ventricle was contracted and 
diminutive. There was an open foramen ovale, and the pulmonary circula- 
tion had been maintained by an open ductus arteriosus, the lungs being thus 
supplied by the aorta. In other cases where the stenosis of the pulmonary 
artery is only partial, the patient may live for years or even reach adult life : 
there is usually an open foramen ovale, or ductus arteriosus, or defective 
interventricular septum ; cyanosis is mostly present, of a more or less high 
grade ; the child easily gets out oi breath, is backward in talking and 

1 See casereported by Hutton in \h&Abstracts, Children's Hospital, Pendlebury, (883, 
p. 45; and Keating and Edwards, Arch, of Pediatrics, p. 134, 1887. 



330 



Diseases of the Circulatory System 



getting on its feet, and is incapable of any great amount of exertion. The 
murmur present is usually loud, superficial, and rasping, being best heard 
over the pulmonary valves, over the second left costal cartilage near the 
sternum. There may be signs of dilatation of the right ventricle, such as 
epigastric pulsation. 

This is perhaps the commonest form of congenital heart disease found 
in children who have survived infancy and early childhood. Such children 
may live to grow up, but are apt to suffer from tuberculosis or to be carried 
off by bronchitis or pneumonia. Post-natal endocarditis is sometimes 
superadded. The diagnosis is not always easy between pulmonary stenosis 
and open foramen ovale without other lesion, especially as the bruit heard 
may result from the presence of both lesions. In pulmonary stenosis there 




Fig. 52. — Congenital Heart Disease, from a child aged ro months. Stenosis of the pulmonary 
artery. «, aorta ; b, pulmonary artery ; c, patent ductus arteriosus. 



is more likely to be cyanosis and a dilated right ventricle, and the murmur 
to be confined to and heard loudest in the pulmonary area. Cadet de 
Gassicourt has reported a case where a bruit was produced through en- 
larged glands pressing on the pulmonary artery. 

Stenosis of the Aorta or Mitral Valves. — In some cases there appears 
to be a congenital smallness of the aorta and arterial system, though it most 
probably is the result of undergrowth, being secondary to some other cardiac 
lesion, by reason of which the arterial system is imperfectly supplied with 
blood. An endocarditis occurring late in fcetal life sometimes affects the 
aortic valves, and an endocarditis may also occur after birth, and still further 
deform or pucker the valves. In such cases, if there is marked obstruction 
at the aortic valves, the ductus arteriosus may remain open, and some of the 



Congenital Heart Disease 331 

blood may pass, as it does during foetal life, from the pulmonary artery into- 
the aorta, without passing through the lungs. The left ventricle will become 
hypertrophied. When the stenosis is only moderate, life may be prolonged 
for many years. Stenosis of the mitral valves may also occur. 

Transposition of the Aorta and Pulmonary Artery. — This curious 
malformation is not uncommon ; the foramen ovale and ventricular septum 
remain open. Life is rarely prolonged for more than a few months ; there 
is much cyanosis, but no bruit is present. A diagnosis during life is hardly 
possible. Of the many other malformations or arrests of development, such 
as a heart consisting of single auricle and ventricle, or a three-chambered 
heart, it is unnecessary to speak. 




F 'g- 53-— Same heart as fig. 52. Right ventricle opened, a, aorta arising from both ventricles ; 
b, pulmonary artery, valves adherent, only admits a large probe ; c, incomplete interventricular 
septum ; d, tricuspid valves. 



Diseases of the Pericardium 

In a few cases a congenital absence of the pericardium or some defect 
in the pericardium has been recorded. In some cases a hernia or diver- 
ticulum has been present ; these congenital defects are of little practical 
interest. 

Pericarditis 



Etiology. — In children, as in adults, the most important association ot 
pericarditis is with rheumatism, acute or subacute, as it arises more often 
during a rheumatic attack than under any other condition. An exception to 
this however occurs, for in children under three years of age rheumatism is 
an uncommon ailment, and pericarditis when present is most frequenth the 
result of an extension of the inflammation from a pleuro-pneumonia or 
empyema, or arises in association with such attacks. It is by no means 



332 Diseases of the Circulatory System 

uncommon to hear a pericardial friction sound during an attack of pneumonia 
in young children, or perhaps to discover post mortem that a pericarditis has 
taken place in a case which was looked upon during life as one of simple 
broncho- or pleuro-pneumonia. In such cases, if they recover, a chronic 
pericardial effusion may remain after the pulmonary lesion has been recovered 
from. 

Pericarditis occasionally occurs during an attack of scarlet fever, either 
.associated with synovitis, or it may be in the absence of any joint com- 
plications. It occurs also during the course of post-scarlatinal nephritis, 
.as a result of a uraemic condition, and under such circumstances must be 
looked upon as of extremely evil augury. It may occur during septicaemia, 
to whatever cause this may be attributed, or in periostitis and ostitis, and we 
have known it supervene in an attack of influenza. 

Pericarditis occurring in a child over three years of age is most frequently 
associated with the rheumatic state. Not that it only occurs during an attack 
of acute rheumatism, for it may supervene when there is no joint pain what- 
ever, or when the joint pain is slight ; but it occurs in a rheumatic individual, 
one who has already suffered from an attack, or who suffers from some of 
the associations of rheumatism, such as chorea, erythema nodosum, or endo- 
carditis. Pericarditis is apt to crop up in an unexpected and unexplained 
manner, and it should be carefully looked for whenever indefinite precordial 
or epigastric pain is complained of. It must be borne in mind that, like 
pleurisy, it occurs in an extremely mild form ; a pericardial rub may be heard 
unexpectedly in the absence of any definite symptoms in children who are 
going about and make no complaint of pain or dyspnoea. These attacks 
pass away, and presumably leave more or less of adhesions between the 
visceral and parietal layers of the pericardium. Does pericarditis recur? 
No doubt it does, in spite of fibroid adhesions and damage to the serous 
3ayer by former attacks. 

Cases of pericarditis occurring during foetal life have been recorded by 
Billard, Bednar, and others. It also occurs in the septicaemia of the newly 
born, secondary to an inflammatory condition of the cord. 

Symptoms. — The subjective symptoms are usually ill defined, especially 
in young children, and are of comparatively little importance as helps to 
diagnosis. The signs and symptoms mostly to be relied on are : (i) The 
presence of a pericardial friction sound. (2) An increased area of cardiac 
dullness proportionate to the effusion present. (3) The disappearance of the 
apex beat, or the position of the apex beat is raised and its area extended. 
(4) There is heart pain and perhaps tenderness on pressure over the cardiac 
region. (1) A pericardial friction sound can hardly be overlooked if carefully 
listened for, and is not likely to be mistaken for valvular murmurs, except, 
perhaps, in the case of infants the subject of congenital heart disease, the 
murmur in such cases being often harsh and superficial. It must not be for- 
gotten that the presence of a friction sound is not incompatible with a large 
.amount of effusion into the pericardial sac. It mostly, however, disappears 
..as effusion takes place, and reappears as the liquid becomes absorbed. 
(2) As effusion takes place into the sac, the area of cardiac dullness is neces- 
sarily increased in proportion to the amount of fluid present. The peri- 
cardium of a healthy child (age 6-9 years) when fully distended contains, 



Pericarditis 335 

according to Sibson, about 6 oz., 1 but much larger quantities than this are 
often present ; the effect of the distension of the sac with fluid is to increase 
the cardiac dullness laterally, and in an upward direction, the lungs, especially 
the left, being pushed on one side, so that the dullness extends to the second 
left costal cartilage, or even as high as the clavicle, and over a corresponding 
portion of the sternum. In lesser effusions the fluid tends to accumulate in 
the lowest part, and so modifies the dullness in a lateral direction. (3) The 
cardiac impulse disappears and the sounds become faint if the effusion is 
large, as a layer of fluid is interposed between the heart and the chest walls. 
Instead of the apex beat disappearing, it may be diffused and raised so as to 
be palpable or visible in the third and fourth spaces, as pointed out by 
Sibson. (4) Pericarditis may take place without any complaint of pain on 
the part of the patient, and hence may be easily overlooked in a mild case. 
In severe cases the pain is referred to the cardiac region, and pressure with 
the fingers or stethoscope causes pain. 

The discovery of a friction sound is usually the first thing to call at- 
tention to the attack. There may be only a slight rub or a loud grating 
sound heard all over the chest. At this stage, where there is no fluid present, 
presuming there is no valvular disease or dilatation, there is no, or but little, 
dyspnoea, probably more or less pain in the chest, quickened pulse and 
moderate fever. The amount of fever present is variable, seldom very high — 
101 F. to 103 F. in a severe case ; the temperature usually falls by lysis 
towards the end of the week. The rub may disappear in a few days in con- 
sequence of adhesions being formed. On the other hand, the friction sounds 
may entirely or in part disappear in consequence of effusion taking place ; 
as the effusion increases dyspnoea becomes more marked ; at first it is 
slight, but if the effusion becomes large the dyspnoea increases, coming on 
in paroxysms accompanied by cyanosis, and there is perhaps a small, ir- 
regular pulse. It must not be forgotten that a considerable effusion may be 
present, and yet a loud friction sound be heard, caused by a small portion 
of the roughened layers of pericardium coming in contact. Death may be 
sudden at this stage, especially in those cases where pericarditis supervenes 
on old heart mischief, and the cardiac walls have become degenerated. In 
other cases the fluid is gradually absorbed, the friction is again heard more 
or less intensely and finally disappears as adhesion takes place. 

No inflammatory affection differs more in intensity than rheumatic peri- 
carditis. There is little doubt that slight attacks occur which are over- 
looked, for a pericardial friction sound is heard at times when least expected, 
and disappears again without producing any symptoms of importance, or 
without the child having been ill, or it may be discovered during an inter- 
current attack of scarlet fever or pneumonia. On the other hand, acute 
pericarditis, or 'acute carditis,' as Dr. Sturges has called it, is a severe and 
dangerous affection, especially when it supervenes in patients whose initial 
valves have been damaged by attacks of endocarditis, and dilatation of the 
heart cavities has occurred. The damaged heart has, v hen surrounded by 
lymph and fluid, to struggle with an increased load, and no wonder the 
prominent feature of the attack is cardiac failure. In these severe cases 

1 In enlarged hearts at this age, the pericardium may contain two or three times this 
amount. 



334 Diseases of the Circulatory System 

there is a quickened and perhaps irregular and intermittent pulse, orthopncea, 
vomiting, with an anxious and worn expression of face. In the worst cases, 
when the effusion of fluid is great, the patient has an ashen or cyanotic look, 
lie sits up in bed leaning forward, and bringing all the extra muscles of 
respiration into play in the struggle for breath. Oedema of the extremities, 
ascites, and pleural effusion may be present. 

In the slighter cases of pericarditis, loose adhesions or attachments may 
take place between the two layers of the pericardium. The result of a single 
attack may be unimportant, but if there are repeated attacks, and they are 
severe, tough and thick adhesions are formed. The heart is thus surrounded 
by a thick fibrous coat, perhaps one-eighth to a quarter of an inch in thick- 
ness, which clogs and impedes the systole of the ventricles. Gradual 
•dilatation of all the cavities takes place with thinning of their walls. This 
condition of things is naturally made worse by an endocarditis, which 
thickens and deforms the mitral and perhaps the tricuspid valves. Thus, as 
an illustration of these results, we may refer to the following case. A girl of 
twelve years, who had suffered from chronic heart disease for some years ; at 
the post-mortem the heart with the attached pericardium and contained clot 
weighed twenty-two ounces, the pericardium was thick and adherent and 
leathery, all the cavities were dilated, the mitral valve had suffered from old 
and recent endocarditis, the tricuspid orifice and the pulmonary artery were 
abnormally wide, the aorta was small, just admitting the little finger, and 
indeed the aorta and its branches were no larger than those of a child of 
three years. No doubt in this case the aorta had failed to develop normally 
on account of the small amount of blood which passed through it. 

An effusion into the pericardium, like an effusion into the pleural cavity, 
may be chronic. It sometimes happens, as we have already pointed out, 
especially in young children, that a pericardial and pleural effusion takes 
place, the latter becomes absorbed, and adhesions form, while the peri- 
cardium remains distended with fluid. If the child is seen for the first time 
when this has occurred, an error in diagnosis is very easy, as the dullness 
caused by a distended pericardium shades away into the impaired resonance 
given by a compressed and adherent left lung. We have several times seen 
in young children fluid aspirated from the pericardium by a needle passed 
into the axilla, when it was believed the fluid was being drawn from the left 
pleural cavity. In these cases, it was found at the post-mortem examination 
the needle had passed through the compressed left lung and entered the 
distended pericardium. 

A chronic pericardial effusion is sometimes present in tubercular sub- 
jects, after the manner of a peritoneal effusion ; this may be of long 
standing, and the diagnosis may be difficult, as the effusion may be 
associated with a mediastinitis and may suggest the presence of mediastinal 
tumour. This was so in the following case : 

Chronic Pericarditis a?id Peritonitis, Contracted Mitral, General Miliary Tuber- 
culosis. — John Hy. P., aged 7 years. Mother states he has always been a healthy boy till 
four months ago, when he had bronchitis; has been wasting ever since; his belly has 
been swelling since. Admitted August 27, 1885. Is an anaemic, flabby boy, with dis- 
tended abdomen, evidently containing much peritoneal fluid ; right side of chest is 
normal; the left is quite dull in front, reaching to the clavicle above, and shading away 



Pericarditis 335 

in the stomach resonance and into axilla, which is also resonant ; the whole cardiac area 
is included in the dull area, the dullness extends to the right just beyond the right sternal 
line ; posteriorly the percussion note is normal ; over the dull area there is bronchial 
breathing both with ex- and inspiration ; there are no moist sounds ; the cardiac impulse 
is not visible or palpable ; cardiac sounds normal ; the veins on the chest are enlarged and 
tortuous; there is marked ascites; the liver is enlarged ; the spleen not felt; urine not 
albuminous. September 24. — Boy continues much in same state; less ascites; the 
temperature continues normal or subnormal ; he does not appear ill or in any way 
uncomfortable ; the glands in the neck under jaw are enlarging. November 11. — Went 
home for a while. Readmitted December 10, 1886. Has been fairly well at home, except 
he has bad cough and his belly has swollen more ; physical signs in chest much the 
same; there is, however, more dyspnoea ; the face has a bluish tinge, and the superficial 
veins on chest more distended ; exploration of chest in dull area with a hypodermic 
syringe ; some straw-coloured coagulable fluid like serum was withdrawn. January 22. — 
Has been getting worse for some weeks past ; temperature has since December 13 been 
99°-ioi°-io3° ; the physical signs have not materially altered, except there is some 
impaired resonance now at base of left lung behind. January 24. — Has been vomiting ; 
pulse 96 ; irregular and intermittent ; temperature 98°-io2°. January 25. — Continues to 
vomit; the ascites has much diminished. Died January 27. Post-mortem. — Some 
emaciation ; some bulging over cardiac area ; on opening chest it is seen the pericardium 
is distended, pushing the left lung away to the left out of sight, the edge of the right lung 
partly overlapping pericardium ; there is a complete matting together of the pericardium 
and mediastinal glands with excess of fibre-tissue ; the mediastinal glands are enlarged, 
containing miliary tubercle ; some are shrunken and pigmented ; the right lung is normal ; 
the left is compressed, surrounded by old adhesions and recent miliary tubercle ; on 
section it is condensed ; recent pulmonary apoplexy ; the pericardium is adherent to the 
parts around ; on cutting into it its walls are nearly \ inch thick, it contains 2 or 3 oz. of 
serum and much loose granular lymph ; heart somewhat small, lymph on the surface ; 
mitral valve only admits forefinger ; tricuspid, z\ fingers ; edges of mitral valve hard and 
sclerotic ; left auricle wall thickened ; left ventricle cavity small ; right ventricle dilated ; 
a few ounces of fluid in peritoneum ; omentum indurated, covered with recent miliary 
tubercles; large and small intestines covered with miliary tubercles ; no ulcers internally ; 
liver adherent to the diaphragm and covered with miliary tubercles ; section fatty ; kidneys, 
a few cheesy tubercles ; spleen normal ; brain, lymph in Sylvian fissures, around cere- 
bellum, and in interpeduncular space ; fluid in the ventricles ; tubercle on the vessels. 

Chronic pericardial effusions are apt to become purulent, and in rare cases 
the pus may find its way to the surface after the fashion of an empyema ; this 
happened in one of our own cases, a child of eighteen months, the abscess 
pointing near the tip of the sternum ; after the abscess was opened the child 
died of exhaustion, and the diagnosis was verified post mortem. In such 
cases there is much difficulty in deciding as to the origin of the pus ; as to 
whether the abscess pointing is a collection of pus finding its way out from 
the mediastinum or from the pericardium. It may also be a local empyema 
or periosteal abscess. 

Complications.— \\\ rheumatic pericarditis, endocarditis is exceedingly 
likely to occur during the attack. Pleurisy or pleuro-pneumonia may be 
present ; more rarely peritonitis and meningitis. 

Diagnosis. — A pericardial friction sound is not likely to be confounded 
with anything else, unless, perhaps, it is an exo-cardiac sound, such as is pro- 
duced by the external surface of the pericardium rubbing against a roughened 
pleura; but this latter is heard only, or at any rate nunc loudly, during 
inspiration. The difficulty most likely to occur is, in a case in which there 
is admittedly old cardiac mischief, to distinguish between dullness due to the 



336 Diseases of the Circulatory System 

presence of fluid and that due to a dilated heart. To anyone who has care- 
fully watched a case from the commencement of the heart disease this diffi- 
culty may be small ; but in cases which are suffering from great dyspnoea and 
distress, in which pericarditis and dilated ventricles exist together, it is often 
difficult to decide when the child is seen for the first time what amount of fluid 
is present and what share it takes in the production of the cardiac distress. It 
must be borne in mind that if the amount of fluid is excessive, there is dull- 
ness as high as the left second intercostal space. In a large dilated heart 
there will be bulging of the chest walls, and an extended area of pulsation 
in part outside the left nipple line. It has been pointed out by several 
writers (Rotch, Dickenson) that dullness extending into the right fifth inter- 
space is probably due to fluid. 

Endocarditis 

Inflammation of the membrane lining the heart, more especially that 
part which covers the valves, occurs at all periods of life. It may attack the 
foetus, and then usually affects the pulmonary or tricuspid valves ; but if it 
occur in the last few weeks of foetal life it may affect the mitral and aortic 
valves. It may also occur during the two or three years succeeding birth ; 
it is, however, less common at this period than later, though it is probably 
often overlooked. It is common during the later periods of childhood and 
youth. Like pericarditis, its usual association is with the rheumatic state, 
not that there is necessarily marked tenderness of the joints and high fever, 
but the patient exhibits some of the symptoms or associations of rheumatism, 
such as chorea, or erythema nodosum, or he has suffered from undoubted 
joint troubles in the past. During an attack of rheumatism, children are 
especially prone to suffer from endocarditis, and the proportion of those who 
do suffer is greater than in the case of adults, being in the case of children 
perhaps 75-80 per cent. ; in adults the proportion must be far less than this. 
Endocarditis also occurs in scarlatinal synovitis ; the heart does not, however, 
so often suffer here as in simple rheumatism. In nephritis, in pyaemia, and 
during attacks of any of the zymotic fevers, especially diphtheria, endocarditis 
may occur. In all febrile conditions a difficulty may arise in the diagnosis, 
in distinguishing murmurs due to organic disease from haemic murmurs. 
During fever the circulation is disturbed and the cardiac beats increased in 
number, the first cardiac sound being wanting in sharpness, or there may 
be a 'murmurish' sound heard ; if this disappears during convalescence we 
are hardly justified in saying that an endocarditis has existed. That endo- 
carditis does occur at times during an attack of scarlet fever or during con- 
valescence is certain ; it is, however, rare to find the valves affected in a fatal 
case of scarlet fever. 

Malignant or ulcerative endocarditis arises in some instances in connec- 
tion with the rheumatic state, being engrafted on to an ordinary rheumatic en- 
docarditis ; it occurs in connection with acute nephritis, suppurative periostitis 
and osteomyelitis. It appears sometimes to follow scarlet fever. Recent 
observations have shown the presence of septic micro-organisms, such 
as streptococci pyog., staphylococci, and Fraenkel's pneumonia diplo- 
cocci on the valves in malignant endocarditis, and it would appear as if a 
simple endocarditis afforded a suitable soil for the development of these 



Endocarditis 



337 



pyogenic micro-organisms. We have several times got cultivations of 
streptococci on gelatine from blood drawn from the finger in cases of 
malignant endocarditis. 

The symptoms of simple endocarditis, such as occurs during rheumatism, 
;are not distinctive. There is often precordial pain, perhaps some dyspnoea, 
usually some fever of an intermittent type (see fig. 54), though this, in some 
instances, may be due to the rheumatism present ; indeed, the only symptom 
■upon which any reliance can be placed is the presence of a bruit ; it is certain, 
liowever, that endocarditis may exist without a bruit being present. It 
sometimes happens that during an attack of rheumatism or chorea the most 
careful examination may fail to detect a bruit, and yet, if the patient is 
examined a month or two after, a bruit is detected, which comes rather as a 
surprise. In the vast majority of cases it is the mitral orifice which is 
affected, a murmur being heard which replaces or accompanies the first 
sound at the apex. Dr. O. Sturges points out that in some cases a faint 
murmur heard at the top of the ensiform cartilage, indicating regurgitation 




Fig- 54- — Temperature Chart of a case of Endocarditis supervening on the sixth day of a mild Scarlet 
Fever ; there were no joint lesions, the bruit persisted, and dilatation of the left ventiicle followed. 



at the ^tricuspid orifice, precedes the mitral bruit, the tricuspid regurgitation 
being due to back pressure through the lungs. The constitutional disturbance 
is but slight, or at least it is impossible to separate the symptoms produced 
by the endocarditis from those produced by the rheumatism. When a re- 
current attack of endocarditis takes place in a case of old heart disease, where 
there is mitral regurgitation and a bruit present, it is rarely possible to make 
a definite diagnosis. 

When the endocarditis is of the malignant or e ulcerative * variety, the 
-constitutional symptoms are usually much more marked, and arc those of 
septicaemia engrafted on to heart disease. It may supervene in a subject 
already suffering from rheumatic- heart disease, post-scarlatinal nephritis, or 
periostitis. In some cases the symptoms are very like those of acute tuber- 
culosis, and in one ease which came under our notice .1 death certificate to 
that effect was given, a subsequent post-mortem showing the real nature 
the disease to be acute endocarditis. In such cases the bruit may be o\ a 
musical character and accompanied by a thrill ; the aortic valves may also 
>be affected and be the seat of a bruit. There is usually precordial pain, often 



338 



Diseases of the Circulatory System 



pain in the left shoulder ; a hectic temperature rising to 103° or 104 in the 
evening and falling in the morning, and enlargement and often tenderness of 
the spleen. The urine is usually albuminous, often highly so. There may 
be joint pain and some of the phenomena of embolism. In one of our own 
cases there was aneurism due to embolism of the middle cerebral artery ; in 
another embolism of the lenticular striate artery. 

In any case of undoubted heart disease with intermittent pyrexia, malig- 
nant endocarditis should be suspected, especially if there is enlargement of 
the spleen and albuminuria. The aortic, tricuspid, and pulmonary valves 
are often affected in malignant endocarditis ; the fact that an aortic bruit is 
heard in a case of acute cardiac disease may help us to decide in favour of 




Fig. 55- — Acute Endocarditis of Mitral Valves in a case of Chorea. (See Fatal Case of Chorea.) 



malignant endocarditis. The following case of malignant endocarditis may 
be taken as an example : 

Malignant Endocarditis — Embolism of Brain and Spleen. — Sarah E. C. , aged 11 years. 
Mother has had rheumatic fever. Four children have died of wasting and convulsions. 
Last Christmas child had chorea for three months and also rheumatism. A month ago 
child complained of pains in limbs. She has a cough and is short of breath, but has 
been going to school up to a fortnight ago. Admitted August 20, 1891. Heart. — Apex 
beat in sixth space, outside nipple line, no thrill, musical systolic murmur at apex, does 
not replace the first sound ; second sound accentuated, no bruit. Lungs, normal. Urine, 
trace of albumen. August 27. — Child has improved. There is a presystolic as well as a 
systolic bruit ; slight presystolic thrill. Temperature goes to ioo° at night. Sep- 
tember 9. — No presystolic murmur now ; rough systolic at the apex well conducted into 
axilla. Temperature 99° to 103 . At 7 P.M. last night child complained of pain in right 
arm and leg. An examination this morning shows complete hemiplegia, the right arm 



Chronic Heart Disease 339 

and leg are paralysed ; there is also facial paralysis of the same side ; knee jerk diminished ; 
plantar reflex present ; slight dropsy of right eyelid ; hemi-anoesthesia of the same side. 
Child not unconscious ; tongue protruded to right ; speech indistinct and thick ; no certain 
loss of memory for words ; she will give the names of common objects ; no optic neuritis ; 
spleen much enlarged, no albumen. November 24. — Patient has been getting weaker 
since last note and more anaemic, her face becoming quite pallid. Temperature has varied 
from 99 to 103 ; the paralysis is much the same, except that contracture has become 
more marked during the last few weeks, and the knee jerk more pronounced. Early on 
the morning of November 24 she became unconscious, the breathing stertorous ; she 
lingered a few hours in this state and then sank. Post-mortem. — Lungs. — Both lungs 
studded with pale infarcts, hypostatic pneumonia at bases of both lungs. Heart. — Much 
enlarged, extending from nipple to nipple ; some two ounces of fluid in the pericardium ; 
no pericarditis. Left ventricle dilated and containing much dark clot ; mitral valve 
covered with large warty granulations which can be readily detached ; posterior surface 
of left auricle is the seat of numerous granulations ; there is also a small patch on the 
surface of the ventricle, where there has been friction or where a flap of the mitral valve 
has impinged. All other valves are normal. Liver. — Congested, nutmeg, and much 
enlarged. Kidneys. — Right kidney contains an infarct of some standing ; left also. 
Spleen. — Very large, contains two large infarcts. Brain. — Brain appears firm and 
healthy. There is an embolus at the junction of middle and anterior cerebral arteries 
on the right side ; there has evidently been embolism of one of the branches of the middle 
cerebral of the left side in the Sylvian fissure, as it is white and apparently plugged. 
Making horizontal sections through the brain, the first section shows some surface soften- 
ing of the left ascending parietal convolution. Section made through the roof of the 
lateral ventricles shows softening of the convolutions of the island of Reil and caudate 
nucleus. Section through internal capsule shows a patch of softening involving the 
lenticular-striate artery, which is plugged with clot and impervious. The softened parts are 
of a rusty colour. The hemiplegia was no doubt due to an embolus in the left lenticular- 
striate artery, and the softening on the surface to embclism of branch of left middle 
cerebral (see fig. 92). 

There are other cases of acute endocarditis, however, which end in recovery at any 
rate for a time. We have seen several cases where there has been pyrexia of an inter- 
mittent type for many months gradually improve, and finally the temperature has become 
normal, and they have been able to get about and appear quite well, but have doubtless 
had damaged mitral valves. 

Chronic Heart Disease 

The immediate result of endocarditis is to cause a swelling and roughness 
of the endocardium which prevents the complete closure of the valves and 
thus allows of regurgitation (see fig. 55) ; puckering and thickening of the 
valves takes place as time goes on, especially if there are recurrent attacks, 
and the valves become permanently damaged. In children it is the mitral 
which almost constantly suffers. In some chronic cases the valves become 
adherent at their edges, and thus stenosis is produced. Gradually other 
and compensatory changes take place ; if the regurgitation occurs at the 
mitral orifice, the left ventricle gradually dilates and becomes hypertrophied. 
At first the compensatory changes which take place are sufficient to prevent 
the patient from feeling any inconvenience, and both he and his friends may 
be ignorant of the existence of valvular disease ; but sooner or later dyspnoea 
on exertion and precordial pain arc complained of, which direct attention to 
the heart. Such patients often suffer from bronchitis— a result of the con- 
stant congestion of the lungs which is present in mitral regurgitation. It" a 
physical examination of the heart is made at this period, a bruit is detected. 



340 Diseases of the Circulatory System 

heard loudest at the apex, but well conducted into the axilla and to the 
angle of the scapula ; the click of the pulmonary valves is accentuated, while 
the aortic sounds are weak. The apex beat is diffused and situated outside 
the nipple line, the cardiac dullness is increased to the left and frequently also 
to the right, as the right ventricle is apt to be dilated on account of the con- 
gested state of the lungs. In some cases the heart becomes enormously 
enlarged, so that the area of cardiac dullness extends from nipple to nipple, 
and the apex beat occupies perhaps the fifth, sixth, and seventh spaces outside 
the nipple line, while the whole of the precordial region is bulged forward 
by the hypertrophied heart. Often the left bronchus is pressed upon and the 
lower lobe of the lung becomes collapsed. During the last stages, which 
may be short or prolonged intermittently for many months or even years, 
the liver becomes congested and enlarged, there is albuminuria from con- 
gested kidneys, while the belly, scrotum, and legs become dropsical. 
Attacks of dyspnoea with pain resembling angina pectoris are not un- 
common towards the last. Such cases may be very chronic, and even 
repeated attacks accompanied by much orthopncea, cardiac distress, bron- 
chitis, and dropsy may be recovered from and the patient once more be 
patched up. In such cases, however, probably no fresh endocarditis occurs, 
and the attack is due more to the engorged state of the lungs and a 
temporarily overworked heart, the latter recovering by rest in bed, and the 
symptoms disappearing as the bronchitis passes off. Should, however, peri- 
carditis occur in a case of old-standing heart disease, the end is not far off, 
as the muscle becomes damaged and further work is imposed on an already 
burdened heart. 

In order to illustrate the lesions most commonly found in chronic heart 
disease in children, we have analysed the results of forty-one post-mortems 
made at the Children's Hospital, Manchester, during the last few years, on 
patients who have been under the care of our colleague Dr. Hutton or -one 
of ourselves. The youngest was three years and eight months at the time 
of death, and the oldest fourteen years. With one exception all died from 
the results of chronic heart disease, that is, the heart disease was primary, 
those cases dying with pericarditis or endocarditis accompanying septicaemia 
or other fatal disease being excluded. They may be divided into the follow- 
ing groups : 

1. Malignant 'ulcerative' endocarditis with embolisms 

in various organs. Pericarditis mostly absent . . 5 cases 

2. Acute pericarditis occurring in a heart already more or 

less dilated from the effects of mitral disease, and 
perhaps old pericarditis. Recent endocarditis mostly 
slight, coincident with the pericarditis .... 20 cases 

3. Adherent pericardium. — Former attacks of pericarditis 

which had given rise to thick leathery adhesions around 
the heart, and in connection with old mitral disease, 
had given rise to extensive dilatation and gradual heart 
failure. A small aorta usually present and dilated 
pulmonary artery ; mostly bronchitis and hypostatic 
congestion of the lungs 10 cases 



Chronic Heart Disease 34 1 

4. Chronic valvular disease without pericarditis. — 

Mitral incompetency, dilatation of both ventricles, 
bronchitis and hypostatic congestion of the lungs . . 6 cases 

In the above forty-one cases the pericardium had been affected thirty 
times ; in the remaining eleven no inflammatory lesion of the pericardium 
had taken place, but clear fluid without lymph was present in several of 
these. In several cases of acute pericarditis the amount of fluid was ex- 
cessive, amounting in one case in a girl of nine years to 20 oz., the heart 
with the distended pericardium measuring 6] in. from right to left ; in 
another the pericardium contained 14 oz. In other cases the cavity of the 
pericardium was obliterated by old adhesions forming a thick layer one-eighth 
to one-quarter inch thick, which had evidently played an important part in 
bringing about the fatal result. 

The mitral orifice was affected in every case ; in the malignant variety 
of endocarditis there were the usual luxuriant vegetations present, mostly 
extending along the posterior wall of the left auricle where the regurgitant 
stream of blood had impinged. In the slighter forms of endocarditis the 
lines of contact of the valves were simply roughened, having lost their shiny 
surface. In other cases there was evidence of old endocarditis, the edges 
of the flaps were thickened, the chordae tendinae were thick and short, and 
in one case several chordae had ruptured. As a result of this and also of 
the dilatation of the ventricles, the mitral orifice was incompetent, the valves 
not meeting during systole, or if coming in contact the roughened surface 
allowing blood to regurgitate into the auricle. In only two cases was there 
any stenosis of the mitral orifice, mostly the orifice admitted two fingers side 
by side, or it was wider still. In one of the cases of stenosis the mitral 
orifice only admitted one finger, the boy had not had rheumatism ; he died 
of tubercular pericarditis and peritonitis (see case, p. 334). In the other case 
the patient was a boy of thirteen, who had been in the hospital five times 
with chorea, and finally with chronic lung trouble. At theftost-mo?-tem there 
were caseation and small cavities in the lungs, no definite tubercle anywhere, 
a puckered and funnel-shaped mitral orifice, and recent and old endocarditis 
of the tricuspid valves. 

The aortic valves Mere affected in twenty, that is, in about half the 
cases, but the lesions were of a far less advanced or serious nature than in 
the case of the mitral. In most of the cases the valves were competent, 
and in no case had regurgitation apparently occurred to any great extent. 
Six times the note was made, ' The aorta only admits the little finger ; ' this 
was due not to the effects of valvular disease but to undergrowth in the aorta, 
which has already been referred to. 

The tricuspid valves were affected thirteen times, or in about one-third of 
the cases, cither by recent or old endocarditis. Probably the tricuspid valves 
were incompetent in the majority of cases in consequence o\ the dilatation 
of the right ventricle. The note often occurs that the tricuspid orifice was 
abnormally wide, and on one occasion it admitted four fingers side by side. 

The pulmonary valves in two cases had slight vegetations on them 
along the lines of contact. In most eases the pulmonary artery was dilated 
from the effects of back pressure. 



34 2 Diseases of the Circulatory System 

The murmurs heard during auscultation in the case of children are in 
some ways more puzzling than those heard in adults. This is due in part 
to the more rapid action of the heart, and this is especially the case in trying 
to time a murmur present in the case of congenital heart disease in an infant. 
In chronic heart disease in children the hearts are larger and occupy more 
space in the chest as compared with adults. Exocardial sounds are 
commoner in children, and may be mistaken for murmurs. 

In acute febrile diseases like scarlet fever or influenza, a murmurish first 
sound may often be heard, and inasmuch as endocarditis does at times 
occur in these diseases, we may at times be in doubt as to whether the 
abnormal sound is due to endocarditis or not. In these cases even an 
experienced ear may be deceived and an endocarditis is suspected, when 
the sequel proves this to have been a mistake. The bruit may disappear as 
the pulse and temperature fall. Certainly, murmurish first sounds are heard 
during scarlet fever, which disappear during convalescence ; but on the 
other hand, an endocarditis occurring during scarlet fever is apt to be over- 
looked. In acute rheumatism or chorea a slight endocarditis may be over- 
looked, inasmuch as it may not give rise to a murmur, the tiny swellings 
along the line of contact of the valves being too minute to allow of re- 
gurgitation, and it is only perhaps after some weeks, perhaps during con- 
valescence, that the murmur is heard. 

Regurgitation through a damaged mitral valve gives rise to a murmur 
accompanying or replacing the first sound at the apex. Post-mortem 
evidence shows that if heart disease exists, there is regurgitation through 
the mitral orifice or damage to the mitral valve in practically all the cases, 
though other valves, as also the pericardium, may share in the damage. In 
the vast majority of cases there is regurgitation and no stenosis. In a con- 
siderable proportion of cases of chronic heart disease in children, especially 
where there is a dilatation of the cavities, there is a double or treble 
murmur at the apex, there being either a presystolic or a diastolic in 
addition to the mitral systolic. The presystolic is generally heard as a 
'churning' or 'rumbling' sound preceding the systolic bruit and running 
up to it. Is the presystolic under these circumstances diagnostic of a 
contracted mitral ? The results of our post mortems lend no support to this 
view. In the two cases in which a contracted mitral was found post mortem 
there was no bruit at all heard during life in one, and a systolic bruit in the 
other. In the cases in which a presystolic and systolic was heard, there 
was no stenosis found post mortem, but in one case ruptured chordae, and in 
others thickened and puckered valves. No bruit is more perplexing than 
the so-called diastolic mitral. This apex diastolic is common enough in 
the later stages of chronic heart disease when there is much dilatation. In 
some cases there is a banging or intensified second sound at the apex, 
produced presumably at the pulmonary orifice, and perhaps the diastolic 
bruit may be what Dr. G. Steell has called 'the murmur of high pressure in 
the pulmonary artery,' which is well conducted to the apex. It can hardly 
be produced at the aortic orifice, as in some cases where it has been heard 
the aortic valves were normal and could not have allowed of regurgitation. 
We have noted this murmur in cases in which the pericardium was adherent, 
and in cases in which it was normal. On several occasions Ave have noted 



Chronic Heart Disease 343 

the presence of a diastolic bruit, and on a later occasion have described it as 
hieing presystolic, and this has been confirmed by others. 

Murmurs produced at the tricuspid orifice are best heard at the tip of 
the sternum, probably they are often masked by the presence of a loud 
mitral murmur. A double bruit at the base indicating stenosis and re- 
gurgitation at the aortic orifice is not common in children, though a systolic 
bruit is common enough. Often the mitral systolic is so well conducted to 
the base that a doubt may be raised as to whether there is aortic stenosis 
-or not. In some cases in which a double bruit has been best heard over 
the pulmonary area, we have found post-mort l em disease of the aortic valves, 
while the pulmonary have been healthy. 

Dilatation of the cavities of the heart takes place in children apart from 
valvular disease, under two circumstances — an excess of blood pressure, as in 
.acute nephritis, the force acting from within and bulging the heart walls as it 
were ; and a chronic pericarditis, with adherent pericardium interfering with 
the systole, and so tending to dilatation ; perhaps this may be aided by a de- 
generation of the cardiac walls. Acute dilatation of all the cavities rapidly 
takes place in some cases of acute nephritis following scarlet fever ; the 
apex beat becomes diffused, and is seen outside the nipple line ; in a few 
cases there is a bruit, clue to the imperfect closure of the mitral valves, and 
symptoms of cardiac failure, and perhaps sudden death may take place. 
Dilatation of the left ventricle may occur in anaemia. Dilatation due to 
chronic pericarditis is a cause of chronic rather than acute heart disease ; a 
pure case of this is rare, as endocarditis mostly occurs also ; but sometimes 
cases may be found in which the heart is enlarged and the cavities dilated, 
with a thick pericardial attachment outside ; the valves are normal or perhaps 
more or less thickened, and have evidently been incompetent during life. 
We have noticed signs of dilated heart with a muffled first sound in growing 
delicate boys towards puberty, especially if they are given to violent exercises. 

Acute Myocarditis. — Acute myocarditis is not a common affection at 
any time of life, and much difficulty exists in stating what it consists in, as 
any general acute process affecting the heart must quickly bring a fatal 
issue. Changes in the cardiac muscles of a coarse description do occasion- 
ally occur. In rare cases children have been attacked with an acute illness 
with fever and delirium, and at the post-mortem an unsuspected abscess has 
been found in the muscle of the heart ; such cases are probably septicemic, 
as also are those where minute abscesses are found. Acute myocarditis 
appears also to occur in diphtheria ; there is a general dilatation of the heart, 
more or less local pain, and dyspnoea followed by a fatal issue, changes being 
found in the muscular fibre of the heart, the muscular fibres being distended 
with fine granules of fat obscuring the strife. It is well known, however, that 
sudden death may occur in diphtheria from paresis of the respiratory mus- 
cles, as well as from disturbed innervation of the heart, so caution is re- 
quired in coming to a conclusion that a myocarditis exists. Steffen has 
described a form of local myocarditis occurring in the course of typhoid, 
accompanied by symptoms of cardiac failure during life. Such cases must 
be rare. Myocarditis or a degeneration of the cardiac muscle may accom- 
pany both pericarditis and endocarditis. Steffen has also recorded cases ot 
myocarditis with dilatation in some cases of purpura. 



344 Diseases of the Circulatory System 

Prognosis.— The prognosis is usually favourable in pericarditis if it occur 
in a hitherto healthy heart ; the rub gradually disappears from adhesion 
taking place. We have, however, known sudden cardiac syncope to occur 
early in the course of a first attack of pericarditis. There is, of course, the 
danger of an endocarditis occurring at a future time, and also the danger of 
the injurious effects of an adherent pericardium. Pericarditis occurring in 
a heart which is hypertrophied from old-standing valvular disease is an ex- 
ceedingly dangerous and fatal affection, and generally marks the beginning 
of the end. Death may be sudden at the last. In endocarditis occurring in 
the course of rheumatism there is, of course, great danger that permanent 
damage may be inflicted on the valves and the patient be handicapped for 
life. On the other hand, there is abundant evidence to show that bruits 
due to endocarditis, occurring either in connection with chorea or rheuma- 
tism, may disappear, and there is no reason why the endocardium may not 
return to its normal condition without crippling the valves ; there is, 
however, the constant fear of a fresh attack at the old spot. The prognosis 
in malignant endocarditis is eminently unfavourable, though cases which 
apparently belong to this category occasionally recover. In chronic heart 
disease the amount of hypertrophy and dilatation present may be taken as 
an index of the damage the heart has suffered. The prognosis in dilated 
hearts secondary to nephritis is favourable if the nephritis subsides and no- 
valvular disease remains. 

Treatment. — The treatment of pericarditis and that of endocarditis have 
so much in common that they may be taken together. It is needless to in- 
sist that the child should be put to bed and religiously kept quiet, all exertion 
and excitement being zealously guarded against. Too much stress cannot be 
laid upon the importance of this, and of maintaining rest in bed long after the 
acute symptoms have passed away. To keep the heart as quiet as possible,, 
and to impose the lightest work on it, during and after the attack, are points 
of the highest moment. The diet given must be suited to the rheumatic state ; 
if peri-endocarditis is associated with it, milk and fluids will form the prin- 
cipal part. Of the local treatment during the acute stage, applications which 
soothe are better than counter-irritants. Ext. of belladonna moistened with 
glycerine may be spread on lint or flannel, and applied to the precordial 
region, and covered with a layer of cotton wool, or spongio-piline wrung out 
of hot water and sprinkled with laudanum maybe applied. If there is much 
pain, a light mustard poultice (one in four or six) kept on for some hours so 
as to redden the skin will usually relieve. Lin. aconiti and lin. iodi, equal 
parts, may be painted over the precordial region. Local blood-letting by 
applying one or two leeches over the sternum is often useful in appropriate 
cases. Dr. D. B. Lees has highly extolled the effects of an ice bag applied 
to the pericardial region. We have seen cases where this method has been 
useful, but some patients rebel against it. Of medicines, salicylate of soda, 
with liq. amnion, acet. if the inflammatory lesion is dependent on the rheu- 
matic state, may be prescribed, tinct. digitalis being substituted and given 
in 3 to 5 minim doses every four hours if there is much dyspncea or 
sign of cardiac failure. Small doses of opium are usually required, and 
are often of the greatest use in relieving pain and quieting the heart's 
action. Half to two grains of Dover's powder may be given at night, 



Chronic Heart Disease 34S 

and repeated once or twice in the twenty-four hours, according to 
circumstances. 

In pericardial effusion, if extensive, tapping of the pericardium may have 
to be resorted to, to relieve the pressure on the heart. Before this is done 
as accurate a diagnosis as possible must be made, to ascertain how much 
the symptoms present, dyspnoea, orthopncea, and cyanosis, are due to pres- 
sure of fluid, and how much to a dilated or hypertrophied heart ; as many,, 
perhaps most, of the cases of children with which we have to deal are in 
reality cases of pericarditis supervening on chronic heart disease. In the 
latter case, if there is much cardiac dilatation and comparatively little fluid, 
paracentesis cannot relieve to any extent, and the cardiac walls may be 
wounded, though, if a fine exploring needle be used, no great damage can be 
done. 1 The spot selected for paracentesis is usually the fourth or fifth inter- 
space, halfway between the left nipple line and the left edge of the sternum, 
but care should be used to ascertain the position of the apex beat as nearly 
as possible. Having by the cautious use of an exploring syringe with a fine 
needle ascertained the presence of fluid a trochar and canula may be used 
to draw it off, care being taken to withdraw the trochar as soon as the 
canula is well inside the cavity of the sac. As a matter of fact paracentesis 
pericardii is rarely of much use, though it may postpone the fatal result a 
few hours, and bring temporary relief. 

In chronic pericardial effusion the inunction of blue ointment or counter- 
irritation by flying blisters may be tried. In chronic purulent effusion,, 
aspiration should be first tried ; if this fails to prevent reaccumulation, 
incision and drainage by an india-rubber tube should be resorted to ; this is 
occasionally successful, as in the case recorded by Dr. S. West. Symptoms 
of cardiac failure should be treated by digitalis, ammonia, ether, or alcohol. 
Ether may be injected subcutaneously or a few drops may be inhaled. The 
treatment of malignant or ulcerative endocarditis is unsatisfactory, and no 
drugs appear to influence its course. The most likely to be useful are 
quinine, digitalis, and the sulpho-carbolates. The treatment of congenital 
or chronic heart disease must be directed to saving the heart all unnecessary 
work and to strengthening it as much as possible. Children with chronic 
heart disease need to be guarded most carefully against the effects of cold, 
as bronchitis is easily contracted in such, and a little bronchitis adds 
materially to the work of the heart, which is, perhaps, at best labouring 
under great mechanical disadvantages. The parents and friends of such 
children must be cautioned against allowing the child to over-tire itself ; it 
is no uncommon thing for such a child to go for a while to the seaside or 
convalescent home and come back worse, for the simple reason that it has 
been on its legs all day, enjoying the novelty of its newly found pleasures : 

1 On one occasion we tapped the pericardium with an exploring syringe armed with a 
large sharp-pointed hollow needle, and withdrew some two ounces of scrum ; this was 
followed by pure blood. After the needle was withdrawn the child became rapidly worse, 
and died in a few minutes. The fost-morttm showed the pericardium full of Mood, and a. 
punctured wound through the right ventricular wall close to the interventricular septum. 
The wall was very thin at this spot and almost fibroid, Had a trochar and canula been 
used, the trochar being withdrawn on entering the pericardium, this accident could not 
have happened. The needle had entered the pericardial sac in the first instance, and then 
entered the right ventricle. 



346 Diseases of the Circulatory System 

whereas a moderate amount only of exercise, insufficient to overwork the 
heart, would have secured an improvement. All active exercise should be 
forbidden, rough games, riding ' cycles,' and gymnastics. The medicines 
of most use to control and regulate the cardiac contractions are digitalis, 
belladonna, iron, and strychnine. Digitalis is of the greatest value, but must 
not be too continuously given ; any intermittency in the beat should be the 
signal for its omission. When dropsy sets in, digitalis with diuretics like 
iodide of potassium, acetate of potash, and squills will be required. In 
excessive dropsy Southey's Canute may be used with advantage. 

XVIediastino-pericarditis, Pleuro -pericarditis 

An inflammation of the serous membrane which is reflected over the 
anterior edges of the lungs and surrounds the pericardium sometimes takes 
place, mostly in association with a more general pleurisy or with pericarditis. 
At times the pleurisy appears to be local, being confined to the serous mem- 
brane covering the pericardium and lung adjoining it. The symptoms of 
such an inflammation are necessarily indefinite, almost the only definite sign 
being a pleural pericardial friction sound — that is, a rubbing sound which is 
synchronous with the cardiac beats, and which is more intense during inspira- 
tion as the lung expands and its edge passes in front of the heart. The rub 
may disappear entirely during expiration. The deeper the inspiration the 
more intense the friction sound becomes. As a result the edge of the lung 
becomes adherent to the pericardium, the space between the two becoming 
obliterated. In some cases a subacute or chronic inflammatory process goes 
on in the mediastinum, involving the serous membranes, connective tissue, 
and perhaps the mediastinal glands, so that a matting of all the parts takes 
place, the edges of the lungs, pericardium, and great vessels being firmly bound 
together. The pericardium may be adherent to the walls of the heart, there 
may be extensive pleuritic adhesions of one or both lungs, and the adhesions 
in some cases are tough and firm and of almost cartilaginous hardness. 

The etiology of these cases is uncertain. Most cases are associated with 
■chronic tuberculosis of the lung or with caseous mediastinal glands ; in 
others no evidence of tubercle can be found, a simple chronic inflammation 
of the connective tissue going on, ending in cicatrisation. The immediate 
result of this process is to hamper the action of the heart, preventing its 
complete systole, to interfere with the filling of the lungs during inspiration, 
and to compress the large veins entering the chest. The liver becomes 
constantly engorged, the hepatic system of veins dilated, and a secondary 
cirrhosis results. 

Symptoms. — The course of this curious affection is very chronic. In 
well-marked cases the symptoms are those which are likely to be caused by 
an obstruction to the flow of blood into the chest. Dyspnoea on exertion, 
cyanosis of the face, clubbing of the fingers, distension of the veins of the 
neck, chest, and abdomen during inspiration, and, later, oedema of the face, 
arms, feet, and abdomen. There may be signs of pulmonary tuberculosis. 
The 'pulsus paradoxus' — i.e. the pulse becoming smaller during inspiration 
— may be present, but certainly it is absent in some cases. In other cases 
the most marked symptom is ascites, with an enlarged liver, suggesting a 



Mediastino -pericarditis, Pleuro-pericarditis ' 347 

primary cirrhosis of the liver ; such cases are exceedingly chronic, and they 
improve if the fluid in the abdomen is removed by tapping, and will go on 
for months or even years ; gradually the portal obstruction becomes greater 
and the patient dies of exhaustion. 1 

The following case may be taken as an example of this affection, running 
an acute course : 

Mediastinals, Ascites. — John E. , aged 2 years. Admitted September 9, 1891. 
Mother states that her first five children are dead. No history of syphilis ; patient had 
convulsions at six months of age. Last May he had a cough and was attended by a 
.doctor. A month later his abdomen began to swell, and soon after his feet ; this has 
gradually increased. On admission his face is puffy, the abdomen is distended with fluid, 
his legs are much swollen. Temperature 101 , pulse 130, respiration 40. Lungs. — There 
is some diminished resonance over the right upper lobe in front ; over both lungs there 
are fine bubbling rales. Heart. — Apex beat in third interspace sounds normal. Abdomen 
'■ is greatly distended, dullness in both flanks and in epigastrium, thrill plainly felt. Liver.— 
. Edge not readily felt, spleen cannot he felt. September 10. — Temperature is 103 , varies 
from 99 to 103°. Crepitation in lungs on both sides. September 14. — Child evidently 
dying ; abdomen relaxed ; edge of liver, both right and left lobe, felt below umbilicus ; a 
nodule about the size of a marble felt in the left lobe. Temperature ios°-io6"-' before 
death. Post-mortem. — Lungs not adherent ; right lower lobe semi-solid with pneumonia ; 
upper lobe of left solid with graines jaunes, but no tubercle. Much yellow fluid in 
abdomen and some lymph on liver, spleen, diaphragm, and great omentum. Heart not 
enlarged ; pericardium thick and adherent, but can be peeled off, leaving a granular sur- 
face adherent to the diaphragm. In the middle and posterior mediastinum there are 
enlarged glands and fibrous tissue. The glands are much enlarged and caseating, one 
size of filbert, several with putty-like contents. Abdomen. — Lymph and tubercle between 
liver and diaphragm, some lymph on surface of liver. Liver much enlarged and granu- 
lar, one boss size of a marble on anterior surface of right lobe near broad ligament, creaks 
when cut, section nutmeg appearance. Spleen enlarged, distended with blood. Kidneys 
pale. 

Raynaud's Disease — Paroxysmal Hsemoglobinuria 

About one-fourth of the cases of Raynaud's disease reported occurred in 
children under ten years of age (J. E. Morgan). Concerning the etiology of 
this disease nothing is known ; in some cases there is a history of malaria, 
but certainly in many of the reported cases there was no such connection. 
In some cases hemoglobinuria has been a prominent symptom, and it is 
believed by some (Dickenson, Abercrombie) that paroxysmal hemoglobinuria 
is a part of the more general disorder which may or may not be present. 

The first symptoms of Raynaud's disease may appear as early as the end 
of the second year, the friends noticing that the child's hands or feet after 
exposure to cold become numb and blue ; the ears and cheeks may become 
easily affected. Before an attack comes on, there is shivering and perhaps 
crying with pain or discomfort. In more severe cases the hands and foe; are 
swollen and of a dark-blue colour. In some of the cases after the attack ;s 
over the child passes urine containing albumen and haemoglobin I. Aber- 
crombie). In other cases no abnormal urine is noted. The exciting cause 
of the attack in all these cases is exposure to cold : the attacks are commoner 
in the winter, and when occurring in the summer the attacks follow a cold 

1 See ' Me diastino-peri carditis in Children,' by 11. R. Hutton, S 
Reports, vol. xiii., and also 'Indurative Mediastino- pericarditis, ' b) 1". Hart-. 
Chronicle^ November 180 1 H >.-w 



348 Diseases of the Circulatory System 

bath or a chill of some sort. In mild cases the attack does not last long ; it 
warmth is applied the blueness and numbness passes off in the course of half 
an hour or less. 

While such is the common type of attack in Raynaud's disease, it happens 
at times that the numbness or blueness of the extremities ends in gangrene 
and spontaneous amputation. A typical case of this kind is recorded by 
Harold (Lancet, February 9, 1895) °f a weakly boy of four years of age ; both 
hands and feet were affected. The hands and feet were blue and numb, the 
hands recovered, but the feet beginning at the toes became gangrenous, and 
a spontaneous amputation of both feet gradually occurred. The boy eventu- 
ally made a good recovery. In these cases there is no doubt a stenosis or 
narrowing of the arteries to the limb or the capillary arteries are affected. 
All children who are liable to these attacks obviously require the greatest 
care in the avoidance of cold, and possibly during cold weather have to be 
confined to bed, or at any rate to one room. The treatment is the treatment 
of symptoms. 



349 



CHAPTER XV 

DISEASES OF THE CIRCULATORY SYSTEM— continued 

wsevus. — Naevus is perhaps the commonest congenital disfigurement 
met with in children ; x usually it is nothing more than a blemish, though 
occasionally it becomes more serious, either from danger to life or serious 
interference with its subject's welfare. Naevi are probably always congenital, 
though not always noticed at birth, since they may not be large enough to 
be conspicuous until some time later. 

Naevi belong to the class of the angiomata, and are defined as 'tumours 
consisting of newly formed blood-vessels,' though it is obvious that they are 
not always tumours in the sense of there being any definite mass of tissue — 
e.g. ' port-wine stains ; ' still this is merely a question of a diffuse as con- 
trasted with a circumscribed growth. 

These growths may be classified as — ■ 

I. (a) Simple angioma, telangiectasis, congenital naevus, mother's mark or 
port-wine stain. The vessels composing the new formation are identical in 
structure with normal arteries, veins and capillaries, (b) Cavernous angioma, 
lacunar or erectile angioma. The blood circulates in a lacunar system as in 
normal erectile tissue. (Cornil and Ranvier.) 

II. Naevi may be considered as (i) arterial, (2) venous, (3) capillary, 
(4) lacunar, blood-vascular growths. 

III. Or, considered from their locality, the naevi may be divided into 
(1) cutaneous : (a) a mere staining or port-wine mark, (b) a distinct mass 
with larger vessels. (2) Subcutaneous. (3) Mixed— i.e. both cutaneous and 
subcutaneous. The different forms of naevi are readily distinguishable. 

Stellate iNeevus. — The so-called ' stellate ' or l spider ' naevus, which is 
doubtfully a new formation, and very probably only a dilatation of pre- 
existing vessels, resembles in appearance the venae stellatae on the surface 
of the kidney of a carnivore. It is most common in the face, disappears on 
pressure, and is closely allied to the mere weather marks of those exposed 
to wind and cold ; it is sometimes seen about the faces of children. 

Port-wine mark consists of a diffuse stain, varying much in size, form, 
position, and colour ; usually there are no obvious dilated vessels, though these 
can be made out on more minute examination. These marks occur, perhaps, 

1 Depaul is quoted by Cornil and Ranvier as saying tint one-third of the children 
born at the clinic of the Faculty of Medicine in Paris have nsevi, and I 
appear spontaneously during the first few months of life. 



350 



Diseases of the Circulatory System 



most commonly on the face, often on the hands, and occasionally else- 
where ; they may cover very large surfaces, such as the whole side of the 
face. There is no elevation of the growth above the level of the skin, only 
the superficial layers of which are involved, and pressure completely obli- 
terates the stain for the time. 

Cutaneous KTsevus. — The common cutaneous naevus is usually small, 
not covering more than a square inch of surface at most ; it is somewhat 
raised above the level of the surrounding skin ; the individual vessels can 
often be distinctly made out, though not always ; the colour of the growth is 
usually vivid red, and on pressure the colour and much of the swelling dis- 
appear, but a slight thickening remains and the skin is l granular.' x These 

growths lie in the corium, and are 
usually sharply defined, but not en- 
capsuled. 

Subcutaneous Naevus. — The 
growth lies entirely beneath the co- 
rium, and forms a distinct tumour \ 
the skin over it is natural in colour, 
or only shows a faint bluish tint ; the 
swelling does not entirely disappear 
on pressure, and is often encapsuled 
more or less perfectly. 2 

Mixed Naevus. — This is a com- 
moner form than the last ; it has the 
characteristics of the cutaneous and 
subcutaneous varieties combined — 
i.e. there is a subcutaneous naevus 
with a cutaneous patch on its sur- 
face ; corium and subcutaneous tis- 
sue are both involved. It is seldom 
that the cutaneous part is as exten- 
sive as the subcutaneous, and in this 
and the last form there is often some 
cavernous formation. 

After removal from the body and 
escape ot its blood, a subcutaneous or mixed naevus consists of a tough, 
spongy, or stringy mass, often somewhat lobulated, and always much smaller 
than might be expected from its size before removal. If encapsuled, it will 
be found that only a small number of vessels, and those of considerable size, 
feed the growth and enter it at various parts— a very important fact as regards 
the treatment of these cases. 

Simple Wsevi consist of newly formed vessels having the structure of 
capillaries, and presenting ampullar or cirsoid dilatations ; the vessels are 
supported by a framework of connective tissue, and often fat. 

Cavernous Wsevi consist of an irregular network of fibrous tissue, in- 
closing freely intercommunicating spaces like the channels in a sponge ; there 

1 Sir J. Paget. 

2 A good account of the structure of naevi will be found in Cornil and Ranvier's 
Histology, to which we are indebted for part of our description. 




Fig. 56.— Extensive ' Mixed ' Naevus of the Face, 
involving the lower lip and both cheeks up to 
the ears. 



Ncevus 



351 



is occasionally unstriped muscular fibre developed in the septa, as well as 
vessels and nerves. The endothelium lining a naevoid lacuna is exactly like 
that of a vein. These naevi are formed by dilatation of newly developed 
capillaries and subsequent absorption of their barrier walls, so that free 
openings are made between adjacent vessels. 

Importance of Ncevi. — Usually naevi are simply disfigurements ; some- 
times, however, they may give rise to serious bleeding from rupture of vessels 
by injury or ulceration, as in a case of our own where the soft palate and 
uvula were the seat of a large naevoid growth and frequent bleeding occurred ; 
similar trouble has been met with in the case of rectal naevi. Internal naevi 
may possibly be dangerous from haemorrhage, or from extravasation of blood 
setting up peritonitis, &c. ; but 
this must be very rare. Some 
very extensive naevi are of im- 
portance from interference with 
the action of the muscles or the 
growth of bones, or from pro- 
ducing unwieldy hypertrophy of 
skin. We have seen fracture 
of the thigh due to weakening 
of the. femur from an extensive 
naevus growth in the limb. 1 Un- 
wieldy overgrowth of limbs may 
occur also from the presence of 
naevi ; and in the case figured 
(fig. 57) the man was unable to 
obtain work on account of his 
disfigurement. We have seen a 
case of pyaemia having its origin 
in a suppurating naevus, and 
another where pyaemia followed 
puncture and partial removal of 
a naevoid growth. 

Changes occtcrring in Ncevi. 




Fig- 57- — Naevus of the face in a mar. of 50. The 
growth was steadily but slowly increasing. The whole 
skin of that side of the face was deep crimson, the lip 
and tongue were involved, and the lower jaw distorted 
and everted by the weight of the enormous lower lip. 
The man died of aortic aneurism. The specimen is 
in the Owens College Museum. 



Naevi sometimes grow rapidly 

from the first and spread over considerable areas ; in many cases, however, 
they grow very slowly, alternately grow and remain stationary, or disappear 
altogether, the last result being especially common in the cutaneous form. 
As Mr. Holmes and others have pointed out, and as we ourselves have seen, 
an illness, especially apparently whooping cough, often seems to bring about 
the cure of a naevus ; possibly the straining in coughing may produce extra- 
vasation and thrombosis in the naevus, and so obliteration. 

Naevi undergo spontaneous cure by fibroid change, the vessels becoming 
obliterated and shrinking into fibrous cords. Such result may follow treat- 
ment, or accidental irritation by friction of the clothes, ov pressure in lying, 
and so on. In other instances calcareous degeneration or thrombosis takes 
place. Cystic change in naevi is very common ; the cysts contain scram. 



The patient was under the care of our colleague, Mr. T. Jot 



352 Diseases of the Circulatory System 

more or less deeply coloured, and arise from the shutting off of a lacunar 
■space or dilated vessel from the blood stream ; the cystic is often combined 
with the fibrous and fatty degeneration. 

Suppuration and ulceration of a naevus is an important condition ; for, 
on the one hand, it may produce a cure by obliteration of the vessels, or, on 
the other hand, as already pointed out, septic absorption or bleeding may 
result ; happily obliteration is the common termination. Various combina- 
tions of these changes may be found going on in a naevus at the same time ; 
pigmentary changes are also found, and sometimes an overgrowth of hair, 
especially in the lipomatous form (vide p. 356). Mere pigmentary maculae 
are sometimes called naevi, but it is better to restrict the name to the vascular 
growth. 

Sites of Ncevi. — Naevi maybe found almost anywhere over the body, but 
there are certain markedly favourite positions. External naevi are most 
common on the head, and of all places we should say the most frequent is 
over the anterior fontanelle ; the lips, cheeks, eyelids, or any part of the 
face may be involved. The trunk and limbs are less commonly affected 
than the face, but perhaps this is partly to be accounted for by the mothers 
being less anxious about naevi on the body ; the labia are not uncommonly 
affected. We have seen a case in which most alarming growth of the naevus 
took place during pregnancy ; subsidence of the swelling followed delivery. 
Different forms of naevi often occur in the same patient — e.g. a port-wine 
mark on the face or hand and a mixed naevus on the scalp. Naevi occurring 
inside the mouth, in the cheeks, tongue, or inner surface of the lip, more 
rarely in the palate, are of course more serious than external ones ; they are 
also much less common. 

Visceral naevi are often seen on the liver, and less often on the kidneys, 
spleen, and other organs ; the muscles and bones are also sometimes affected. 
It is common to see naevi on the skin of meningoceles both cerebral and 
spinal — a fact noticed by Mr. Holmes, and one of some importance from a 
diagnostic point of view. 

Several cases of rectal naevi are on record, among others one mentioned 
by Mr. Barker which caused death by haemorrhage. 1 We have met with a 
case which exactly simulated piles, and was cured by ligature. The extent 
of tissue involved is sometimes very great, as already stated ; thus we have 
seen the whole lower extremity naevoid, and Mr. Barker has recorded a case 
of the whole upper extremity being so affected 2 (vide also fig. 57). 

Treatment of Ncevi. — It should be a rule of practice not to interfere with 
naevi unless they are growing or have been stationary for some time, since, 
as already pointed out, very many disappear of themselves. The important 
points to consider for each naevus are whether it is cutaneous, subcutaneous, 
or mixed, and what is its relation to important adjacent structures, which 
maybe endangered by treatment or by the resulting scar. It is unnecessary 
to mention all the methods proposed for treating these growths ; only the 
most efficient will be described here. Stellate naevi may readily be cured 
by puncturing the centre of the star with a hot needle. Port-wine marks 
require careful consideration as to whether the resulting white scar will not 

1 Brit. Med. Jour. 1883. 2 Clin. Soc. Trans. 1884. 



Ncevus 353 

be as disfiguring as the red mark, and it must be remembered that in cases 
where a large surface is involved a long course of treatment is required to 
remove the mark. 

Linear scarification, multiple puncture, the actual cautery or a caustic, 
such as fuming nitric acid, and in some cases electrolysis, will succeed. 
From five to twenty or more cells of a Stohrer's or Weiss' battery should be 
used. If large, the patch should be treated in sections, so as not to have too 
large a sore surface at once. 

Cutaneous naevi are best treated with the actual cautery ; if small, a heated 
needle is sufficient ; in larger growths Paquelin's cautery is the most useful 
instrument. Narrow lines may be scored across and across the naevus, or 
multiple punctures employed ; after using the cautery once, as soon as the 
wound is healed, it will often be found that little patches remain unoblite- 
rated : these should be watched for some weeks before reapplying the cautery, 
as they often shrink subsequently without further operation. The cautery 
should be at a dull red heat, and should be applied deeply enough to reach 
through the naevus. Ethylate of sodium is fairly efficient, but usually requires 
several applications, and is not, we think, better than the cautery ; it has the 
advantage of not requiring the use of an anaesthetic, though it is followed by 
a good deal of temporary smarting. For port- wine stains the ethylate may 
be applied every two or three days according to the effect produced, and 
then, if required, fresh applications may be made after two or three weeks. 
Vaccination on a naevus is not a good plan. For subcutaneous or mixed 
naevi we cannot recommend injections of any kind ; they are often efficient, 
but always dangerous, extensive thrombosis or embolism, causing immediate 
death, having followed their use ; if they are employed, a temporary ligature 
should be put round the naevus and removed a few minutes after injection. 
Ligature of naevi is uncertain, as well as tedious and troublesome. We think 
treatment by excision, by multiple puncture with the cautery, and in suitable 
cases by electrolysis, is the most generally useful. 

Excision is applicable to well-encapsuled growths of small or moderate 
size, not involving important structures. There are certain essential points 
in the operation : first, the incisions must be carried well wide of the growth 
and not within its capsule ; there will then be only a few well-defined vessels 
to secure, and not a freely bleeding cavernous tissue, as is the case if the 
growth is cut into ; next, the skin in a mixed naevus, if the cutaneous part 
is very small, should be removed as far as it is involved, provided always 
the edges of the wound can afterwards be brought together easily so as to 
obtain primary union. If the skin is widely involved, it should not be taken 
away, but, as suggested by Mr. Teale, dissected off the naevus and preserved : 
this, however, necessitates opening up thcnawoid tissue, and complicates the 
operation ; sometimes also the cutaneous naevus continues to grow afterwards. 
A bloodless method of excising naevi is that oi~ passing long needles or 
harelip pins beneath the base of the growth crosswise, then winding an 
elastic thread round the needles and excising the growth after dissecting back 
skin flaps ; the needles are then withdrawn and the vessels are secured. 
There is no bleeding until the elastic is removed.' Degenerated naevi should 
nearly always be excised if they are treated at all ; in some instances, where 
1 A plan devised, wo believe, by Mr. Davies Colley. 



354 Diseases of the Circulatory System 

there is cystic degeneration, a seton passed through the cyst causes it to 
shrink ; but there is a certain amount of danger in this plan if any part of the 
naevus remains undegenerated. 

The little galvano-caustic apparatus devised by Mr. Golding-Bird for 
enucleating lymphatic glands we have used with good effect for large mixed 
naevi not removable by excision. 

In using the actual cautery the fine or middle-sized point of the Paquelin's 
cautery is entered through the skin and made to traverse the naevus in several 
directions from one puncture ; if the naevus is large this is repeated at another 

spot, and so on ; a little vaseline 
is then applied to the cauterised 
surface and the effect is watched ; 
after all contraction has ceased 
another portion is, if necessary, 
attacked, until the whole mass 
has shrunk. 

Pressure is occasionally 
successful as a means of treat- 
ing naevi, but is chiefly applicable 
to cases where other treatment 
is impracticable, as in very ex- 
tensive naevus of a limb ; l it 
may be employed successfully 
sometimes in naevus of the scalp, 
where the underlying skull forms 
a firm basis ; especially if com- 
bined with subcutaneous break- 
ing up of the naevus with a 
tenotome. In cases of ulcera- 
tion of naevi, and in some severe 
cutaneous forms, scraping away 
the growth with a sharp spoon 
will sometimes do good. 

Importance of Nccvi in spe- 
cial Localities. — Naevi occurring in certain localities have more than ordinary 
importance, either from the difficulty of their treatment or diagnosis or from 
the risk attaching to them. Naevus of the lip is often found involving the 
whole thickness of either lip, and is usually either of the mixed or sub- 
cutaneous variety ; the surface is somewhat prone to ulceration in the mixed 
form from constant irritation, and the growth is often very unsightly. If 
degenerated and cystic, or if there are large cavernous spaces in the naevus, 
it may be mistaken for a labial mucous cyst or for lymphatic macrocheilia. 
Puncture from the mucous aspect with the Paquelin's cautery is usually the 
best mode of treatment, but in some cases it is a good plan to excise a 
segment of the lip and bring the edges together as after a harelip operation. 
Orbital naevi are usually associated with similar growths upon the face : 
they may cause exophthalmos and ectropion ; the naevoid character of the 

1 A good case of the effects of pressure under such circumstances is recorded by Hardie, 
Lancet, May 1885. 




Fig. 58.— Orbital Naevus. The growth extended deeply 
causing exophthalmos and ectropion, and spread up- 
wards upon the forehead. 



Ncevus 



355 



growth is indicated by the spongy feeling and the possibility in some cases 
of pushing back the protruding eyeball and so emptying the growth of blood . 
Treatment by electrolysis is the only serviceable method in these cases. 

Naevus of the tongue may give rise to macroglossia and cause protrusion 
of the organ, or may be limited to a small part of its surface : it is liable to be 
mistaken for lymphatic macroglossia or for a mucous cyst. The colour will 
usually serve to distinguish it from the former, though the two conditions 
seem to be sometimes combined, and the compressibility of a naevus will 
mark it off from the latter affection ; in doubtful cases a grooved needle will 
clear up the difficulty. The actual cautery, or in rare cases excision, of a 
part of the tongue is the treatment required. In one child we excised the 
anterior third of the tongue by a A-shaped incision, and brought the sides 
of the wedge together with sutures ; the result 
was good and repair was rapid. A similar 
condition may be met with on the gums or inner 
surface of the cheeks. Sometimes large blood 
lacunas are met with beneath the tongue, look- 
ing like ranula ; the soft palate and uvula are 
also occasionally affected ; in one instance 
where both conditions existed the sublingual 
naevus was cured by the actual cautery, and the 
uvula removed by the galvanic ecraseur ; the 
patient was attacked by pyaemia, but ultimately 
recovered completely. 

Naevus of the eyelids must be treated with 
great caution to prevent any subsequent distor- 
tion ; it is best usually to attack small portions 
at a time with the actual cautery and wait until 
cicatrisation is complete before a second application. The same rule applies 
to naevus of the nose where too vigorous treatment may produce an unsightly, 
sharp-pointed, beak-like appearance if the skin is too much destroyed. In 
some instances excision is the better plan. 

Naevi around the orbit are sometimes very difficult to diagnose, especially 
if they are degenerated, and consequently have lost their colour ; dermoid 
cysts, meningoceles, simple serous congenital cysts, and fatty g'rowths should 
be borne in mind as sources of fallacy. In one instance (fig. 58) there was a 
cyst with none of the appearance of a naevus ; on tapping it, altered blood 
escaped, and on incision it was found that the growth was loculated and in 
part solid (i.e. degenerated). A seton was passed through it at last after 
failure of incision and drainage, excision being out of the question, and the 
mass suppurated freely, but unfortunately erysipelas occurred and the child 
died. At the post-mortem the orbit and cavernous sinus were found full o\ 
more or less degenerated naevoid tissue ; the naevus spaces were mostly full 
of blood, and minute abscesses were seen with the microscope in sections 
of the growth. 

Speaking generally, most nan i can be recognised by the presence oi the 
remains of some superficial naevoid tissue by the possibility o\ reducing the 
size of the growth by pressure this point must not, of course, be allowed to 
mislead in swellings about the head or spine and by the peculiar spongy 

A V J 




Fig. 59. — Arteriovenous varix. 



356 



Diseases of the Circulatory System 



feeling. This sensation is sometimes to be felt in a growth where solid 
masses are also perceptible. The fact that the tumour is congenital or has 
been noticed in very early life, and occasionally the presence of extravasa- 
tion of blood in the skin, as well as, of course, the results of tapping, will 
usually clear up a doubt. 

Certain rare forms of vascular deformity are occasionally met with in 
children. In a case of our own the condition may be best described as 

arterio-venous varix, all the vessels being 
dilated and pulsatile ; the facial, orbital, 
and intracranial vessels were involved as 
well as some of the cerebral sinuses, the 
straight sinus being converted into a. 
pouch as large as a thrush's egg and its. 
walls calcified l (fig. 59). 

Aiieurism by a?iastoi)iosis is also oc- 
casionally met with in children, and 
sometimes ligature of a main vessel,, 
such as the carotid, may be required, 
as also in some cases of arterial varix. 
St. Germain relates three cases of cirsoid 
aneurism cured by the use of chloride 
of zinc arrows. ( Vide ' Chirurgie des 
Enfants,' 1884.) 

Ncevus Upomatodes is the term ap- 
plied to a form of degenerated naevus 
in which there is much development of 
fatty tissue forming masses which often 
hang in pendulous folds ; there is com- 
monly pigmentation and hairy over- 
growth. The condition is rare, and 
appears to be associated with idiocy,, 
as in the typical case under our care,, 
from which fig. 60 was taken. No 
treatment is called for in such a case. 2 
We have recently (1895) seen a female 
infant a few weeks old with an almost 
exactly similar condition. Occasionally, 
however, Avhere merely a local mass is 
found, it should be removed by excision. 
This was the treatment adopted for 
the child shown in fig. 61, where the- 
pendulous hairy mass, closely resembling the so-called ' pachydermatocele,' 
was excised with a good result. 

lymphatic Neevi Lymphatic nsevi are much rarer than blood naevi,. 

but many of the so-called congenital cystic growths should be classed as 

1 A full report of the case here alluded to will be found in the Abstracts of the 
Children's Hospital for 1882-83. Vide also T. Smith, Clin. Soc. Trans. 1882. 

2 Hyde of Chicago has recorded a very similar case in the Lancet, August 1,. 
i88v 




Fig. 60. — Naevus Lipomatodes. The darkly 
pigmented pendulous masses were com- 
posed of fat and degenerated naevus tissue, 
and the whole surface was thickly over- 
grown with hair. As usual in these cases, 
the child was idiotic. 



Ncbvus 



357 



-cystic lymphangiomat.a. Instances of this condition are seen, as shown by 
Virchow, in macroglossia, described at p. 167. 

Hygroma and one form of so-called ' giant foot ' are similar conditions, 
■fig. 62. Sometimes in giant foot the cutaneous lymphatics are clearly visible 
as transparent, dilated, tortuous canals running in the skin : the part is greatly 
enlarged, and spongy on pressure. The disease is a rare one, and probably 
pressure or cautery puncture would be the most successful mode of treatment. 
Treves has recorded a case in which ulceration had occurred, and quotes 
Busey that congenital giant foot is commoner in females, and most frequent 
in the right leg ; the temperature of the part may or may not be raised. Ulcers, 
if they occur, readily heal. 

Occasionally in macroglossia, as in a case of ours, the superficial lym- 
phatics form minute transparent cysts on the surface of the tongue ; here 





.>' 



Fig. 62. — Lymphatic Naevus of the 
Foot. The soles of the two feet are 
seen, and in the affected one the 
extremities of the toes can just be 
made out, embedded in the mass of 
naevus tissue. Dilated and varicose 
lymphatics were visible in the skin. 



Fig. 61. — Degenerated Naevus of Scalp. 

removal of part of the tongue might possibly be required to prevent suffocation, 
since these growths are liable to rapid increase in size. Alarge tumour of the 
thigh, of congenital origin, that we removed a short time ago from a child of 
2^ years, was made up of spongy tissue exactly like a naevus, but the spaces 
were filled with lymph instead of blood; other similar cases have been 
recorded. (F/Vfcalso chapter on Tumours.) 1 loggan has described multiple 
lymphatic nana of the skin, a condition believed commonly to accompany 
blood nsevi, and to be much more frequent than is supposed : these growths 
are not conspicuous by their colour, and are therefore commonly overlooked : 
they arc of little clinical importance, unless probably as an early stage >*: 
elephantiasis. We have also met with instances of these n.e\i.' Cases ot 
1 Hoggan, Jour, of Anat. and Phys. April 1884. La \cet x t88a, vol. ii, p 



358 Diseases of the Circulatory System 

probably congenital lymphatic varices of the limbs have been described by 
R. W. Parker ; he thinks they have a tendency to become locally inflamed. 1 
We have recently met with a case of lymph naevus of the conjunctiva and 
supra-orbital region, causing an unsightly deformity ; the naevus varied much 
in size, and sometimes ' puffed up ' and became painful. - 

Large multilocular cystic swellings may be met with in the neck, re- 
sembling in external appearance the hygromata which are associated with 
lymphatic macroglossia, but differing from these lymphatic tumours in that 
some of the cysts are found filled with blood either coagulated or more or 
less altered, and become ' laky.' In the same swelling cysts may contain 
fluid clear or only tinged with blood. It is difficult in such cases to be sure 
whether the growth is a blood naevus which has undergone cystic degenera- 
tion, or a lymph naevus into which haemorrhages have taken place. Such a 
case which we saw with Dr. McNicoll, of Southport, occurred in a child of 
seven weeks old ; and as it was growing and threatened to cause dyspnoea, it 
was treated by laying open and partly removing the larger cysts. The opera- 
tion, though extensive and formidable for so young a child, had a satisfactory 
result. 

Aneurism in children is extremely rare ; only a few cases have been re- 
corded, and these appear all to have been either traumatic or the result of em- 
bolism, the embolus giving rise to softening of the arterial coat, and consequent 
formation of the aneurism. A paper on this subject by R. W. Parker in the 
' British Medical Journal,' 1884, may be consulted. We have only met with 
one case of aneurism, in a child aged seven years, who was suffering from ulcera- 
tive endocarditis ; the aneurism, which was situated on the left middle cerebral 
artery, was no doubt due to an embolus ; it finally ruptured and gave rise to 
extensive meningeal haemorrhage. Dr. A. Jacobi has reported several 
cases of aneurism in children, due to atheromatous degeneration, one case 
of the descending aorta in a girl of seven years. Sanne has reported four 
cases, one in a foetus, and three in children of two, ten, and thirteen years 
respectively. 

1 Vide also chap, on Tumour Growths in Childhood. 

2 The case, with a drawing, has been published by Dr. Mules in Trans. Ophthalm. 
Cong., Heidelberg, 1888. For an account of various rare abnormalities of the blood and 
lymph vascular systems (also Nerveti-Naevus, &c.) the reader is referred to Esmarch and 
Kulenkampff s monograph on Elephantiasis. 



359 



CHAPTER XVI 

DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS 

Anaemia 

Children of all ages are liable to suffer from anaemia, from causes both 
known and unknown. Some children are habitually pallid, without, perhaps, 
being in any way out of health ; and this peculiarity seems to run in families. 
In the majority of cases anaemia means ill health, the poorness of blood being 
due to one or other of a great variety of ailments. It is unnecessary for 
us to describe the anaemia which is due to obvious causes, such as tuberculosis, 
heart disease, syphilis, malaria, or the anaemia which is the result of some 
acute disease. We will chiefly confine our remarks to certain forms in which 
the anaemia is often profound and the pathology by no means certain. A 
slight acquaintance with the forms of anaemia from which children suffer will 
be sufficient to convince anyone that there are different forms of diverse groups. 
Thus we have anaemia accompanied by great enlargement of the spleen, and 
an anaemia in which no such enlargement is present. We have the so-called 
Pernicious Anaemia, which appears always to go on to a fatal issue. In some 
cases there is a tendency to purpura, and while in all forms of anaemia 
haemorrhages are common when the anaemia becomes extreme, yet in some 
cases purpura is an early symptom, and makes its appearance without the 
anaemia being very great. The groups into which we divide these cases are 
selected rather for convenience of description than from their actually form- 
ing independent or ' self-standing forms ' of disease. 

It is unnecessary to say that an examination of the blood gives important 
information with regard to the nature of the anaemia, and is therefore of use 
as regards prognosis and treatment. For the details of the methods of this 
examination we must refer the reader to the various clinical manuals. 1 

The examination includes (i) The estimation of the amount of haemo- 
globin present as measured by Fleischl's haemometer. In healthy children 
there may be 85 to 95 per cent., in profound anaemia as little as 30 to 35 per 
cent. (Fischl). 

(2) Counting the number of the red and white corpuscles, by means o( 
the Thoma-Zeiss apparatus. In round numbers in healthy children there are 
five million red corpuscles to the cubic centimetre ; in some forms of anaemia 
the number may sink to two millions. The number of white corpuscles varies 
from 8 to 9,000 (Limbeck) in children, to ie to 13,000 (GunrobhY in infants 
under a year. 

(3) A microscopical examination of the rod corpuscles to determine 
shape, size, and colour. In extreme forms of anaemia there may be some 

1 Or see Kanthack'On Blood Changes in Diseased Conditions,' 

July, August, October 1894. 



360 Diseases of the Blood and Blood-making Organs 

nucleated red corpuscles present, and the corpuscles may be misshapen and 
very pale. 

(4) A film of dried blood is stained with eosin and methyl blue in order 
to distinguish between the varieties of white corpuscles present, and to deter- 
mine their relative proportion. Following Ehrlich's methods, Kanthack dis- 
tinguishes the following varieties : 

(a) lymphocytes, consisting of small cells with a large blue nucleus and 
narrow zone of clear protoplasm ; they are supposed to derive their origin 
from lymphatic gland tissue, (b) large uninuclear cells, consisting of 
cells with a large oval or indented nucleus, and a large zone of surrounding 
clear protoplasm. They are supposed to be derived from the marrow of 
bone and spleen, (c) Finely granular or polynuclear (neutrophile) cells. 
The nucleus is multipartite, and lobed. The protoplasm is filled with granules 
which stain with eosin. The number of these cells is increased in febrile 
conditions : they are in normal conditions in adults the most numerous of 
the white corpuscles present, (d) Coarsely granular eosinophile cells : 
they have a single round or horseshoe nucleus, the protoplasm has coarse 
granules which stain strongly with eosin. 

As regards the relative numbers of these in the blood of healthy adults 
and infants, the following numbers may be taken as approximately true. 
Lymphocytes, adults 20 per cent., infants under one year 59 per cent. 

Large uninuclear cells, adults 6 per cent., infants 6 per cent. 

Finely granular neutrophile cells, adults 75 per cent., infants 31 per cent. 

Coarsely granular eosinophile cells, adults 2 per cent., infants 3 per cent. 
(Uskoff), (Gunrobin). 

From this it would appear that in early life the lymphocytes are increased 
at the expense of the finely granular or neutrophile cells. 

Anaemia with (Edema, — In all cases in which the anaemia is great there 
is a tendency to the accumulation of serum in the serous cavities, and a 
liability to subcutaneous cedema. In the out-patient department of hospital 
practice it is common to meet with infants or children under two years of age 
who are anaemic, and at the same time cedematous, the back of their hands 
and feet readily pitting. Such cases are often looked upon as suffering 
from nephritis, but the urine is mostly free from albumen and casts. There 
is usually no enlargement of the spleen. These cases are commonly seen in 
the autumn in children who have suffered from acute diarrhoea or some other 
exhausting disease which has given rise to great anaemia. The anaemia is 
due to the great drain on the system during acute or long-continued disease, 
or possibly it may be the result of the action of toxic albumens or peptones 
absorbed into the blood from the alimentary canal. We must also remem- 
ber that the arterial pressure in young children is normally very small, and 
easily reduced by acute disease. (See Nephritis.) 

Simple Anaemia Chlorosis.— There is a class of case mostly occurring 
in older children which resembles the chlorosis of adults. There is no 
enlargement of the spleen, no purpura or any evidence of organic disease. 
The children are markedly bloodless, languid, and easily get out of breath ; 
murmurs may be heard at the base of the heart, and in the veins and arteries 
of the neck. Both girls and boys may be affected in this way about puberty. 
In one instance coming under our notice, two brothers and a sister, aged 8^, 
7, and 5f years, suffered in this way ; their mother was also anaemic. They 



Ancemia 



361 



were intensely anaemic, and were drowsy and lethargic. They were fairly well 
nourished as far as fat was concerned ; there was no splenic enlargement, 
no albumen in the urine, and no haemorrhages. In all three there was an 
irregular pyrexia, a rise of a degree or two taking place most evenings. An 
examination of the blood showed a diminution of red blood corpuscles, and 
no striking excess of white corpuscles. They all three improved consider- 
ably during their stay in hospital. It is well to bear in mind that such cases 
•are excedingly apt to suffer from tubercle. 

Idiopathic or Pernicious Anaemia is apt to occur in children ; out of 
102 cases published by Dr. Pye Smith in the Guy's Hospital 'Reports' for 
1882 there were six between the ages of seven and fifteen years. It has been 
met with in children of all ages. Kjellberg has recorded a case in a boy of 
five years, Elben in a girl of three years, and W. Steffen in a girl of sixteen 
months. It is always fatal. 

No cause can usually be assigned for the anaemia ; in one case coming 
under our notice the child had been much neglected and badly fed. 
Schopiro reports a case of a girl of 13 years who was supposed to suffer 
from pernicious anaemia, but began to improve after passing a tape-worm — 
Bothriocephalus latus. 

The symptoms and course are exactly the same in children as in adults. 
The first symptoms are those of weakness, breathlessness, and pallor, coming 
on without cause. The anaemia becomes extreme, the skin is blanched and 
of an earthy tinge ; the conjunctivae and mucous membrane of the mouth 
are pallid, and the muscles weak and flabby. Usually there is no great loss 
of flesh. Vomiting is not uncommonly a marked symptom. In some cases 
there appears to be a slight rise of temperature at night, 101 or 102 ; in this 
respect pernicious anaemia resembles other forms of anaemia. Purpuric spots 
are sometimes present on the skin, and retinal haemorrhages and optic 
neuritis may take place (S. Mackenzie). 

An examination of the blood in an advanced case shows a very marked 
diminution of the red blood corpuscles without any leucocytosis, indeed the 
white corpuscles are usually diminished, and a considerable number of large 
red corpuscles (niegaloblasts) are present. In a case of pernicious anaemia 
which, as we have already remarked, is an exceedingly fatal disease, dia- 
gnosis is of great importance. It is most likely to be mistaken for some form 
of secondary anaemia, in which there has been severe haemorrhage, or the 
feeding has been bad as in scurvy. The following are the chief points to be 
noted in examining the blood. See Kanthack (loc. cit.). 



Chlorosis 

Red blood corpuscles slightly 
reduced in number ; Hb 
considerably reduced. 

Red corpuscles retain their 
size and shape, nucleated 
red corpuscles rare. 

No leucocytosis. 

No large red corpuscles 
present. 



Secondary Ancemia 

Red blood corpuscles re- 
duced ; marked decrease 
of Hb. 

Nucleated red corpuscles 
present; red corpuscles 
vary in size and shape. 

In acute eases (here is leuco- 
cytosis due to an in- 
crease in the number of 
the polynuclear leuco- 
cytes. 

No large red corpuscles. 



Pernicious A ncemia 

Red blood corpuscles greatly 
reduced, Hb diminished, 
but not in proportion, 

Nucleated red corpuscles 
extremely common; they 
are easily injured. 

No leucocytosis 
diminution. 

Large red corp 
present. 



362 Diseases of the Blood and Blood-making Organs 

The course is often acute, usually varying from one month to three 
months. 

Morbid Anatomy. — All the organs are in a bloodless condition, the 
muscles are in a state of fatty degeneration, and minute haemorrhages are 
found on the surfaces of the organs. There is no further alteration found 
in the spleen or other viscera. 

The following case illustrates many of the above points : 

Pernicious Ancemia. — Walter H., aged 11 \ years, has been getting pale and weak for 
six months, no cause known ; has had hollow cough and frontal headache ; for two 
months has had frequent epistaxis, and for some time has had fainting fits, and spots 
' like bruises' have appeared on thighs and shins ; no bleeding from lungs or bowels 
noticed. Mother strong, father said to have been phthisical in early life ; brothers and 
sisters all rickety and anaemic, four of them now in hospital with scarlet iever ; all re- 
covering. Admitted August 30. Large, well-formed, well-nourished, and muscular boy, 
dark brown hair and eyes, height 4 ft. 7 in., intelligent, intensely anaemic, tongue furred, 
pale and fissured, fauces pale, tonsils large ; respiration 34, fairly deep ; pulse 146, regu- 
lar and full ; temperature 103 ; both bases dull, with weak respiratory sounds, no crepi- 
tation, heart's area normal, impulse heaving and visible over second to fifth spaces, sounds 
at left base murmurous, spleen and liver not felt in abdomen, blood watery and pale ; red 
corpuscles, generally normal in shape and form characteristic rouleaux, a few are elon- 
gated ; white corpuscles only slightly increased relatively, vary much in size, most of them 
being smaller than usual ; urine 1016, pale, no albumen, no excess of urates or phosphates ; 
ordered citrate of iron. August 31. — Temperature now between normal and ioo°. 
September 6. — Temperature still below ioo° ; respiration 32; pulse 148; no cough, no 
night sweating, has attacks of syncope on attempting to sit up, has vomited twice to-day, 
no cardiac murmur. Died September 7. 

Post-moriem. — Forty hours after death body well nourished, intensely anaemic, rigor 
mortis persists, a few ounces of serum in each pleural cavity, patches of emphysema 
along margins of lungs, no consolidation, abundant sub-pleural ecchymoses ; about 2 oz. 
clear serum in pericardium, no pericarditis, no endocarditis, abundant sub-pericardial 
ecchymoses, tricuspid orifice admits three fingers, muscular fibre pale ; much ' tabby-cat ' 
mottling of endocardium. Spleen 3^ oz. , soft and friable ; liver 34^ oz., very anaemic ; 
kidneys 4,5 oz., very soft, intensely anaemic, capsules peel off readily. 

Baginsky * records a case of pernicious anaemia in a child of 3^ years. It 
suffered from haemophilia for a year before its death. When seen it was very- 
pale, the liver and spleen were enlarged. An examination of the blood 
showed only 2,680,000 red blood corpuscles per ccm., and only 17 per cent. Hb 
(Fleischl). The proportion of white corpuscles to red 1 in 100. The red blood 
corpuscles had undergone change of shape ; there were megaloblasts and 
nucleated red corpuscles, many large uninuclear cells, and a small number of 
the multi-nuclear. No eosinophile cells. 

Treatment. — The medicines most likely to be of service are iron and 
arsenic. Phosphorus and cod liver oil have been used with some success. 
Bone marrow and raw meat juice should be given. In the majority of cases 
the progress is from bad to worse. 

Scurvy. — A scorbutic state may sometimes be met with in children as the 
result of bad or improper food, especially if fresh vegetables have been 
excluded from it ; such are cases of true scurvy, similar in every respect to 
those which used to occur so frequently among seamen. A similar condition 
is met with in association with certain depressing diseases such as tuberculosis. 
At other times when it occurs it is difficult to assign any cause. 

1 Berliner Kiin. Woch. 20, 1894. 



Enlarged Spleen 363. 

The patient is usually anaemic, though he may be well nourished as far 
as subcutaneous fat is concerned ; the gums are spongy and offensive, they 
bleed with the slightest injury, the teeth are loose and may fall out ; haemor- 
rhage is apt to occur from the nose, kidneys, and bowels ; purpuric spots are 
common, and bruising occurs after the slightest injuries. The majority of 
the cases which come under our notice in hospital quickly improve with 
proper dieting and careful nursing. In one of our cases, where a scorbutic 
condition was present in a boy of ten years in association with fibroid phthisis, 
improvement took place on several occasions when we had him in hospital,, 
but he eventually died from exhaustion, the result of frequent haemorrhages. 
At the post-mortem a chronic tuberculosis was found, but nothing was 
found to explain the haemorrhagic condition suffered from during life. A 
scorbutic condition is not infrequently associated with rickets in young 
children. (See Rickets.) 

Treatment. — In all cases where there is anaemia, with spongy gums and a 
tendency to haemorrhages, lemon or orange juice should be given, and fresh 
vegetables in some form or other should enter into the diet. Scraped 
underdone meat, beef juice, and eggs should be given. The gums should be 
carefully cleansed, and painted with glycerine of tannin, borax and tincture 
of myrrh, or some other antiseptic. Iron and cod liver oil should be given 
internally. Haemostatics, such as ex. hamamelis liq., gallic acid, and turpen- 
tine, will often be required. 

Enlarged Spleen 

The spleen is a very vascular organ, is functionally more active in child- 
hood than in after life, and is more apt to become temporarily engorged 
and enlarged. The best method of determining the enlargement during- 
early life is by palpation rather than by percussion, as the lesser rigidity of 
the abdominal walls during early childhood usually readily permits of this. 
Palpation of the spleen is effected by standing at the patient's right side 
and gently pressing two or three fingers of the right hand into the left hypo- 
chondrium beneath the costal arch, when the lower and inner edge of the 
spleen if it is enlarged can be readily felt as a movable tumour which can be 
pressed upwards. It can hardly be said that the spleen is abnormally en- 
larged unless its lower edge extends below the costal arch. Enlargement is 
very common during childhood, and accompanies various conditions. An en- 
larged spleen is most frequently associated with an anaemic condition, though 
exactly what the relation between the two is is uncertain (see p. 364). An 
enlarged spleen is met with when the portal system is interfered with, as in 
cirrhosis of the liver. In two cases coming under our notice the spleens 
were greatly enlarged, and in these cases it is quite possible to overlook ihe 
cirrhosis of the liver and look upon the case as one in which the splenic 
enlargement is due to Hodgkin's disease or some anaemic condition. It is 
enlarged in many cases of rickets and syphilis, though certainly not in all 
cases; it is chiefly so in those cases in which pallor and anaemia are marked 
symptoms. It is enlarged and hard in ague, and also when lardaceous and 
in association with leucocythaemia and Hodgkin's disease, h is also en- 
larged in various acute diseases, such as typhoid fever, acute tuberculosis 



364 Diseases of the Blood and Blood-making Organs 

and pyaemia, and in some other febrile states, such as ulcerative endo- 
carditis. 

Anaemia Splenica. Anaemia Infantum Pseudoleukaemica. — In an 
ill-defined group of cases, occurring mostly in children under two years of 
age, the anaemia is often profound, and the spleen strikingly enlarged. 
Sometimes mothers will bring such children for treatment, as they have 
already noticed the large spleen as well as the paleness of the child. There 
is usually a history to be obtained of ill health, more especially of aggravated 
indigestion, or some acute illness, and nearly all of them exhibit evidence 
of rickety deformities. In a well-marked case, the anaemia strikes the 
■observer at once as being much out of the common ; the lips are a 
pale pink, and the face is white or of a slightly yellow tint ; on placing 
the hand on the abdomen, the edge of the spleen is distinctly felt (it can 
sometimes be seen), and the tip can be traced downwards on a level with, 
or below, the umbilicus. There may be enlargement of the liver. The 
urine is free from albumen, and except quite at the termination of the case, 
there are no haemorrhages and no oedema. There is often irregular and 
intermittent pyrexia. The course is essentially chronic : the patients usually 
"improve slowly under treatment in hospital with careful diet and tonic 
medicines. They readily succumb to intercurrent diseases, such as measles 
or pneumonia. In the worst class of case the anaemia becomes more and 
more profound, they die exhausted ; in the later stages there may be 
haemorrhages, purpura, and oedema. On the other hand, we meet with 
; borderland : cases, where there is a moderate degree of anaemia and splenic 
enlargements, with perhaps well-marked signs of rickets. The pathology 
■of these cases is very obscure ; an examination of the spleen post mortem 
shows it to be hypertrophied, firm., and hard, and on section it is of a dark 
purple colour ; a microscopical examination shows nothing beyond hyper- 
trophy. The etiology of these cases is no less uncertain. The condition 
closely resembles that seen in malaria, but in this country this can be ex- 
cluded with certainty. In a certain proportion of the cases a history of 
syphilis can be obtained ; in thirty cases reported by Carr l there was a 
history of syphilis in eight, a doubtful history in six, and in sixteen no history 
could be obtained. In sixty- three cases reported by Fox and Ball a in forty- 
one per cent, there was a history of syphilis to be obtained. The figures of 
the last observers surprise us ; our experience has been that a definite history 
of syphilis is uncommon, and certainly in a large majority of our cases no 
history of syphilis could be obtained. It is true that syphilis produces both 
anaemia and enlargement of the spleen, especially during the acute phases ; 
but we are not aware of any cases of syphilis having been under observation 
during the acute stage and having then passed into (while under observation) 
a condition of splenic anaemia. That there is a close connection between 
this condition and rickets is certain, as almost all "such children exhibit 
-evidence of rickety changes in the bones, and this anaemic state occurs 
almost exclusively during the first two years of life, when rickets is most 
common. We are inclined to agree with Carr in believing that, while both 
syphilis and rickets may play a role in producing this condition of splenic 

1 Lancet, April 23, 1892. 2 Brit. Med. Jour. April 1892. 



Ancemia Splenica 365 

anaemia, they are neither of them the sole or efficient cause, but that con- 
genital weakness, chronic dyspepsia, bad feeding, and insanitary conditions 
may interfere with the blood-making organs and lead to a condition of pro- 
found anaemia. 

Hock and Schlesinger * draw a distinction between Ancemia infantum 
pseitdolenkcemica and Ajicemia splenica. The first rather awkward-sounding 
name was applied by Jaksch to cases in which there was anaemia, en- 
larged spleen, and leucocytosis ; the latter to a class of case in which there 
was ancemia, enlarged spleen, but no leucocytosis. How far this distinction 
can be maintained we are not prepared to say, but there is a strong pro- 
bability, Ave think, that there may be different causes at work in producing 
anaemia with splenic enlargement in young children, and we are hardly 
in a position to accord to this class a position among the ' self-standing y 
diseases. 

In three cases in which the blood was examined by Felsenthal 2 in children 
(ages ten months to one and a quarter years), in which there was marked- 
anaemia, enlarged spleen, with a comparatively small liver, no lymphatic 
enlargement, and well-marked signs of rickets, he found that the amount of 
haemoglobin was as low as thirty to forty per cent, the number of red cor- 
puscles about three million per cubic centimetre, the leucocytes forty to forty- 
five thousand, there were many nucleated red blood corpuscles, and some very 
large red ones (megaloblasts). The number of lymphocytes varied from 4a 
to 60 per cent. In one of our cases, a girl of fourteen months, our resident 
medical officer, Dr. H. Wansborough Jones, on examination of the blood 
found 2,800,000 red corpuscles and 112,000 white corpuscles per cu. milk 
The haemoglobin amounted to thirty per cent. There were some nucleated 
red corpuscles, and some megaloblasts and microcytes. No eosinophile 
cells were seen. 

While in a vast majority of cases the children who suffer in this way are 
under two years of age, yet occasionally we meet with older children who 
are affected in a similar manner, as in the following fatal case : 

Ancemia, Enlarged Spleen. — Thos. Arthur C, aged 5 years. Up to four months ago 
quite healthy ; no serious illness. Has lived always in Manchester. Father and mother 
healthy. Four months ago had a fall, not confined to bed, abdomen painful and swolleit 
ever since, two months ago had severe epistaxis, with no known cause ; very much blanched 
ever since, feet sometimes swollen ; has had occasional pain and twitchings in left arm for 
an hour at a time, and slight twitchings of the body also. On admission, December 29, 
1881, plump, with marked pallor, a few purpuric spots on thighs and feet ; superficial 
glands generally enlarged, face cedematous, no oedema of feet ; abdomen prominent in 
epigastric and hypogastric regions, liver and spleen much enlarged, heart and lungs nil. 
Urine 1020 ; no albumen. Temperature 103° P.M. June 2. — Loud systolic murmur over 
whole cardiac area, no mediastinal dullness; heart's area increased, apex beat felt outside 
nipple line. Blood thin and watery, with some increase of white corpuscles : spleen 
rather tender. Temperature irregular, 98° to roi° and 102°. June 13.— Constantly 
moaning; temperature still high and irregular. June 14. — Died 5 A.M.. unconscious 
all night. Post-mortem, — Twelve hours after death ; great pallor, some oedema of ex- 
tremities ; blood very fluid, liver uniformly enlarged, pale with tine yellow points 
(hepatic vessels). No perihepatitis, spleen 5 in. by 3 in. ; smooth, firm, purple on section. 

1 Hcematologische Studien, Leipsic, iSoj. 

- Archiv filr Kinder htilkunde x Heft. i. n. ii 189a. 



2,66 Diseases of the Blood and Blood-making Organs 

Retroperitoneal glands very slightly enlarged ; kidneys firm and very pale. No peritonitis, 
•no ascites, no staining of organs with iodine. Heart. — Left ventricle hypertrophied ; 
right ventricle dilated, subpericardial ecchymoses, valves normal. Lungs emphysematous, 
•with abundant ecchymoses on surface and in substance. No enlarged mediastinal glands ; 
brain firm, intensely anaemic, otherwise apparently healthy. No venous congestion, no 
fluid in ventricles. 

Treatme?it. — Iron, arsenic, and cod liver oil, especially the former, are the 
drugs most likely to be of service in anaemia, though the treatment must 
necessarily be modified according to the cause. The cachexia produced by 
syphilis must be treated by a combination of iron and mercury, quinine if 
malaria is suspected. Care must be taken to see that the bowels are acting 
normally. 

Raw marrow of bone, raw meat juice, orange juice, peptonised milk 
-should be given. 

Hodgkin's Disease — Anaemia lymphatica. — This disease is character- 
ised by an enlargement of various groups of lymphatic glands and also of 
the spleen ; there is progressive anaemia, and more or less intermittent fever. 
According to Gower's statistics, 16 out of every ioo cases occur in children 
under ten years of age. The earliest symptom which calls attention to the 
disease is enlargement of some lymphatic glands, usually the cervical, though 
the axillary or mediastinal may be early affected. 

The glands just behind, or in front of and beneath, the sterno-mastoid are 
frequently the first to be enlarged, or the group at the angle of the jaw ; the 
-glands at first are firm and movable, varying in size from time to time as if 
the vessels were gorged at one time and more empty at another. With the 
glandular enlargement there is usually a marked increase in size of the 
spleen, and the child becomes weak and pallid. A prominent feature of the 
disease is the occurrence of attacks of pyrexia ; the temperature at times 
continues elevated for some days, or it may assume the intermittent type. 
Other groups of glands may become affected ; there may be an extension 
mto the mediastinum, and the glands may exert pressure on the trachea or 
large veins, so that there is orthopncea, oedema, or ascites. The axillary 
and inguinal glands may also become affected. In some cases the external 
lymphatic glands may be but little affected, but the mediastinal or retro- 
peritoneal glands and the spleen may be much enlarged. The course of 
the disease is very chronic, but the prognosis is unfavourable, and sooner or 
later the child dies exhausted. At the autopsy the spleen is found enlarged 
and infiltrated with an adenoid growth, while other organs, as the lungs, 
liver, and kidneys, are also infiltrated, only in less degree. 

Diagnosis. — The diagnosis of Hodgkin's disease in an early stage is often 
extremely difficult where the patient is brought with a mass of enlarged 
glands in the neck or other part. If the glandular tumours vary in size from 
time to time, if there is intermittent pyrexia or enlarged spleen, Hodgkin's 
disease may be suspected. If the glands suppurate they are probably 
tubercular. We have frequently seen enlarged tubercular cervical and 
axillary glands mistaken for the enlarged glands of Hodgkin's disease. 
Possibly tubercular disease and Hodgkin's disease may co-exist. 

Treatment. — Arsenic and phosphorus are the medicines most likely to be 
useful, but the disease generally progresses to a fatal termination. 



Hemorrhagic Diathesis 367 

Leukaemia. — Leukaemia is a rare disease during childhood, but the 
possibility of its being present should be borne in mind when a pallid child 
with a large spleen presents itself, especially if on examination of the blood 
there is marked leucocytosis. It occurs at all ages : babies at the breast 
have been affected, and also those more advanced in years ; it cannot be 
said that anything certain is known about its etiology, though poor living, 
various depressing conditions, and malaria have been credited with producing 
it. The earliest symptom to call attention to the disease is abdominal 
distension, which is found to be due to a greatly enlarged spleen ; with this 
there is dyspepsia, perhaps abdominal tenderness, and marked anaemia. 
The disease is a chronic one, and the prognosis unfavourable. Like 
Hodgkin's disease, there may be enlargement of lymphatic glands and 
intermittent pyrexia. Later in the disease the anaemia becomes profound, 
oedema of the subcutaneous tissues takes place, and often there are 
haemorrhages. 

Two forms of leukaemia are distinguished, the mixed form in which the 
spleen and marrow of the bones are mostly involved, and the lymphatic 
variety in which the lymphatic glands are enlarged. An examination of the 
blood may solve the difficulty. 

Kanthack gives the following diagnostic points to enable the two varieties 
to be distinguished from one another and also from Hodgkin's disease : 

Hodgkin's Disease 

Red corpuscles slightly di- 
minished. 

Hb slightly diminished. 

Slight changes in the red 
corpuscles. 



Spleno-medullary A?icemia 
Red corpuscles diminished. 



Lymphatic Leukcemia 
Red corpuscles diminished. 



Only moderate leucocytosis 
due to an increase of lym- 
phocytes and perhaps neu- 
trophile cells. 

Treatment. — Arsenic, 
likely drugs to be of use. 
be tried. 



Hb diminished. 

Red corpuscles vary in size 
and shape, many nuclea- 
ted. 

Enormous leucocytosis, in- 
crease in large hyaline and 
eosinophile cells ; small 
relative number of lympho- 
cytes. 

phosphorus, cod liver oil and iron are the most 
Mercurial inunctions over spleen and glands may 



Hb diminished. 

Rarely nucleated red cor- 
puscles. 

Enormous leucocytosis. 

Great increase of lympho- 
cytes, other kinds dimi- 
nished. 



The Haemorrhaglc Diathesis. 

During early life a disposition to bleed arises under many different con- 
ditions. In some cases this disposition to bleed is hereditary, in others it is 
the result of many different forms of illness. We will consider the hereditary 
variety first. 

Haemophilia. — This term is applied to a disposition to bleeding which is 
hereditary ; it affects males more often than females, but the females often 
appear to transmit this tendency to their sons. This tendency to bleed may 
only appear in one or two members o[ a family, the rest escaping, but those 
who thus escape may transmit the diathesis to their children. Haemophilia 
does not usually appear at the time of birth, the disposition usually first 
manifesting itself after the end of the fust year oi life. It is true that newly 
born children are apt to bleed from the nave! or suffer from h,rmaten\ 



368 Diseases of the Blood and Blood-making Organs 

but this is the result rather of some disease than from inherited tendencies. 
Children who exhibit this diathesis seem to exhibit it in different degrees at 
different times ; sometimes they appear to bruise on the slightest injury, while 
at other times there is hardly any tendency in this direction. Purpura or 
' bruising ' is the most common manifestation ; slight pressure or a slight 
knock on a limb, such as might take place by the nurse catching firmly hold,, 
will suffice to bring out a well-marked bruise, which is many days in fading. 
Sometimes a number of haemorrhagic spots make their appearance spon- 
taneously, and in the same way extensive subcutaneous bleedings may take 
place. A slight scratch or cut may ooze blood for some time before it stops, 
cracks or fissures in the skin of the lips may ooze in the same way. Of the 
mucous membranes perhaps the gums most often bleed — friction with a tooth 
brush may be enough to start a haemorrhage. Epistaxis is also very common,, 
and may be very difficult to stop. There may be haemorrhage from the 
stomach from straining when vomiting, or blood may appear in the stools. 

Haematuria also takes place at times. Haematomas of the scalp are liable 
to follow slight falls, or injuries and bleedings of considerable amount may 
take place in the muscles and other deeply situated structures. Bleedings 
may take place into the joints, especially the knees. It may be the result of 
injury, but in some cases this does not appear to be the case. The joints 
appear swollen and tender, and contain fluid— the fluid gradually disappears 
with rest ; but if repeated bleedings occur much thickening of the synovial 
membrane with overstretching of the ligaments and nodular swellings,, 
resulting in distortion and more or less permanent crippling of the joint, may 
result. A joint into which haemorrhage has once taken place is apparently 
likely to suffer again. We have seen patients lamed for life in this way. 

We have also met with a case in which, in addition to haemorrhage into 
joints on several occasions, bleeding took place beneath the palmar fascia^ 
causing great pain, and a somewhat alarming appearance of the hand. The 
blood was, -however, slowly absorbed, and no serious ill result followed. It 
occurred in the patient, of which the following notes were taken : 

Hcemophilia, Effusion in Knee Joint. — L. , a boy of 14, was first seen in September 
1890, with Dr. Massiah. There was no history of haemophilia in the family. At 
Christmas 1889 he sprained his left knee, and it at once filled with blood, and has never 
been well for any length of time since. The left leg is smaller than the right, and is said 
to have always been so. "When seen in September the left knee was enormously distended 
with fluid blood, and was a good deal hotter than the other. His brother, who was seen 
at the same time, had numerous bruises, and one ankle contained fluid blood, which was 
becoming absorbed and giving rise to discoloration of the adjoining parts. On examining 
the knee thirteen days later it much resembled a joint the subject of chronic rheumatic 
arthritis ; there was thickening of bone and crackling of the joint, with occasional : locking.' 
The limb could not be fully extended, and there was \ inch shortening. In April 1892 he 
was seen again ; the knee was again swollen after an injury, though not to the extent of the 
former attack. 

Perhaps the most serious complication of all is a cerebral haemorrhage, 
This may be the result of a blow or a knock, or it may apparently occur 
spontaneously. Thus a girl of 3| years, who had had from time to time 
bruise marks on her skin, suddenly developed symptoms of paralysis of the 
re spiratory muscles, and she died asphyxiated in three or four days. At the 



Purpura HcemorrJiagica 369 

post-mortem a haemorrhage into the medulla was found. (See case under 
Medullary Haemorrhage, p. 480.) 

The prognosis in all these cases of haemophilia is necessarily uncertain. 
They are carried off in many cases by intercurrent disease, to which they fall 
an easy prey, or as the result of some accident. It is certain that some 
reach adult life, as examples of this condition are not uncommon among 
adults. 

The diagnosis is not difficult in a well-marked case, but there may often 
be a doubt as to whether the disease is hereditary or whether it has super- 
vened on some form of disease, but in the hereditary form the history of 
bleeders in the family will necessarily be of help. 

Very little is known for certain about the pathology of these cases. It 
has been supposed that there is some congenital affection of the arteries or 
the capillary vessels, which allows the blood to easily ooze through their 
walls, but this has not been substantiated. We must be content for the 
present to confess our ignorance. 

No children require so much care or are greater causes for anxiety than 
habitual bleeders. No operation, however slight, can be permitted in these 
cases. Gum-lancing, excision of tonsils, drawing teeth, opening abscesses, 
must be avoided. They must be carefully watched and guarded in every 
relation of life. When bleeding is going on turpentine, hazeline, ergot, and 
gallic acid are the most likely drugs to be of service. Tr. ferri perchlor. may 
be applied locally. When bleeding has taken place into a joint, the child 
should be kept in bed with the affected joint fixed in a splint and cooling 
lotions applied. After a week of rest, if no recurrence of the bleeding takes 
place, very gentle movement and rubbing should be employed to prevent 
stiffness and favour absorption of the blood as perfectly as possible. All 
violent exercises must be avoided by these children ; they are, in consequence, 
a source of constant anxiety to their friends. 

Purpura simplex, Purpura haemorrhagica. — These terms are applied 
to conditions in which thehaemorrhagic diathesis has been acquired, that is, is 
not hereditary. The name P. simplex is applied when the bleeding is sub- 
cutaneous only, that of P. haemorrhagica when the bleeding takes place from 
various sources besides the skin, such as kidneys, &c. 

Purpura haemorrhagica occurs under a number of different conditions. 
Thus it occurs (i)in malignant smallpox and measles, in typhus, occasionally in 
scarlet fevet, in acute ileo-colitis, and especially in diphtheria ; in these cases 
it is no doubt due to the presence of albumoscs in the blood ; (2) in various 
anaemic conditions, especially towards the latter stages, when the anaemia is 
severe, such as scurvy, pernicious anaemia, Hodgkin's disease, rickets and 
syphilis ; (3) we have it following attacks of gastric catarrh, diarrhoea, croupous 
pneumonia, whooping cough, in rheumatism and also in meningitis. 

It occurs at times without being associated, as far as can be made out, 
with other diseases ; but it may be doubted if it is ever an independent disease. 
In most cases, at any rate, some other disease precedes it, and it seems rather 
to occur as the result of changes effected in the blood by the pre-existing 
disease. 

Purpura sometimes makes its appearance .is a mild affection, at other 
times it is acute and quickly fatal, Thus a child may present itself with 

B B 



370 Diseases of the Blood and Blood-making Organs 

large and extensive ecchymoses on the limbs or trunk, but it is not in the least 
ill, and the subcutaneous bleedings disappear in a few weeks or less. Or 
perhaps a child is seized in the midst of apparent health with ecchymoses 
and severe haemorrhages from the kidneys or from the alimentary canal ;. 
there is delirium, and then coma and death in a few days. Sometimes purpura 
accompanies a type of disease which resembles scurvy more than anything 
else, and yet there has been no deprivation of fresh food or hardship of any 
sort. As an example of this we may relate the following case : 

Purpura Hemorrhagica. — Guy F., aged 6 years. Was always a fairly healthy boy 
till August 1889, when he had a severe attack of diarrhoea, with collapse, at the seaside, 
He never completely recovered himself, being pale and weak. At the end of the following 
January he suffered from spongy gums, occasional vomiting of dark blood, and frequent 
bruise marks on his body. He continued much in the same state for the next month, 
when (February 14) he tripped and fell, striking his head against the edge of a table. A 
haematoma of the scalp quickly formed on the right side of his forehead ; during the same 
night the fingers of the left hand twitched continuously, and the grasp on that side was 
feeble. Next day the grasp of left hand was very weak, and there was some difficulty in 
flexion and extension of the wrist. P'our weeks after the accident the haematoma and 
bruising had nearly disappeared, and power had mostly returned in the left hand. He,, 
however, continued to go downhill, there was pain in the stomach and frequent vomiting, 
oozing of blood from the nose, and purpuric spots appearing on the trunk and limbs. A 
loud, rough bruit was heard over the whole heart area, he became more and more anaemic, 
and there was marked wasting. He was unconscious for 20 hours before death, which 
occurred at the end of March. Post-mortem. — Excess of clear fluid in the serous cavities ; 
punctiform bleedings on surface of heart and lungs ; no valvular lesion ; muscle of heart 
pale, left ventricle dilated. Stomach much dilated ; walls of stomach and also of intes- 
tines very thin. Spleen enlarged and soft. Extensive subarachnoid haemorrhage over 
surface of the brain ; some red fluid between dura and arachnoid. On the right ascending 
frontal convolutions is a haemorrhage, circular in shape, involving the width of the convo- 
lution, extending an inch into brain substance. The bleeding had involved the hand centre. 

The ecchymoses which occur vary much in size and number ; in rare cases- 
the greater-part of an arm or thigh is of a dark purple colour from haemor- 
rhage beneath the cutis. In other cases the purpuric patches vary in 
size from mere points like haemorrhagic flea bites thickly scattered over 
the skin to patches the size of the palm of one's hand. In erythema nodosum 
the nodes, which are first of a rosy tint, become in a day or two purple from? 
capillary haemorrhage. In rare cases patches of subcutaneous haemorrhage- 
become gangrenous ; Sangster has recorded such a case. A girl of 5 years 
had several purpuric patches on the extremities and cheeks ; one of these 
on the arm ended in gangrene, recovery eventually taking place. Steffen has 
collected several more cases, in which multiple skin gangrene occurred after 
purpura ; the cases proved fatal. 

In a number of cases haemorrhage occurs either on the surface or into the 
substance of the brain. We have already referred to two such cases comings 
under our notice, one in which there was medullary haemorrhage, and the 
other in which a small bleeding occurred in the Rolandic area. Grosz (loc 
cit.) records a case where there was a haemorrhage the size of a nut in the 
substance of the right lobe of the cerebellum, and also beneath the pia mater.. 
Steffen has collected four fatal cases in which meningeal haemorrhage or 
haemorrhage into the brain substance was found post mortem. In some cases 
1 See Grosz, Ueber Purpura im Kindersalter : Archivfiir Kinderheilk. Heft i. u. ii. 1894. 



Retro-peritoneal Glands 371 

there has been evidence of brain haemorrhage, in which recovery has taken 
place. Haemorrhage has also been found in the substance of the spinal 
cord. 

Steffen reports cases in which a myocarditis occurred in the course of pur- 
pura, leading to dilatation of the left ventricle ; and a consequent inefficiency 
of the mitral valves. In such cases a mitral murmur will be heard during 
life. (See cases, p. 370.) Haematemesis is not uncommon. Indeed, vomiting 
is frequent, the vomited matter being streaked with blood, probably from 
punctiform bleedings taking place in the stomach. Blood in the stools also 
occurs in these cases, and punctiform bleedings are frequently found post 
mortem. Haematuria is a frequent symptom ; in some cases there is 
albuminuria and no blood present. 

The association of purpura with rheumatism is an interesting one. Schon- 
lein gave the name of Peliosis rheumatica to a form of purpura in which the 
joints were affected. Probably Steffen is right in altogether dropping the name, 
inasmuch as the so-called Peliosis rheumatica is purpura in which there has 
been bleeding into the joints or the muscles or tissues around the joints. In 
true rheumatism purpura does occasionally occur, and as is well known 
Erythema nodosum occurs in association with rheumatism. 

As a rule an attack of purpura is feverless, but in some cases there is 
moderate fever, especially before the appearance of a crop of petechias. In 
the acute cases, such as have been described by Plenoch, Pye-Smith, and 
others, in which there is vomiting haematemesis, haematuria, petechiae, delirium 
and coma, there may be a high temperature. 

An examination of the blood during an attack shows a diminution of the 
haemoglobin and of the red corpuscles. The leucocytes may at first be in 
slight excess, but they also diminish in number. Micro-organisms have been 
found, but as yet bacteriology has shed but little light on the pathology of 
this disease. Experimentally, it has been shown that the presence of 
peptones and albumoses in the blood give rise to haemorrhages and many of 
the symptoms of purpura. 

Concerning the prognosis in purpura little can be said. Purpuric smallpox 
is well-nigh always fatal, and purpura occurring during the course of diph- 
theria is an extremely bad omen. In malignant scarlet fever and also in 
malignant measles the rash is at times said to be purpuric. We have never 
seen such cases, but on several occasions we have seen the rash in both 
diseases assume a purpuric appearance, and recovery take place without a 
bad symptom. In some forms of anaemia with wasting, the appearance of 
purpura marks the beginning of the end. Purpura simplex is always of less 
grave import than those cases in which haemorrhages occur from internal 
organs. 

The treatment of purpura is the treatment of haemorrhage generally. 
Among the most valuable haemostatics are turpentine (\X\y xx), ex. hamamelis 
liq. (]]\v ])\xx), ex. ergotae liq. (n\v lt\xx), ergotine by subcutaneous injec- 
tion, gallic acid (gr. v gr. x), and acetate oi load (gr. J gr. i). 

Diseases of the Retro-peritoneal Glands.- -There are a considerable 
number of lymphatic glands situated behind the peritoneum, at the back of 
the abdomen and in the pelvis. They are most numerous lying along the 

b 1; _- 



372 Diseases of the Blood and Blood-making Organs 

vena cava inferior and aorta and their branches. These glands may become 
enlarged and caseous in tubercular disease, or may be the starting point of a 
lymphadenoma or abscess. When caseous, they are so in association with 
mesenteric disease ; in one case under our care the caseous glands surround- 
ing the vena cava completely compressed the latter, giving rise to cedema of 
the lower limbs and enlarged veins on the surface of the abdomen. In 
another case a lymphadenomatous tumour exactly simulating an enlarged 
spleen, which had commenced in some retro-peritoneal glands, was first noted 
in the left hypochondriac region. It grew to an immense size, occupying 
nearly half the abdomen. Some of the more obscure forms of abdominal and 
pelvic abscesses appear to originate in these glands. 



373 



CHAPTER XVII 

TUBERCULOSIS 

In speaking of chronic tuberculosis of the lungs we have emphasised the 
fact that, in children far more commonly than in adults, the tubercular lesions 
not only affect the lungs, but are widely distributed through the body (see 
p. 249). It is the general distribution of tubercle which often renders the 
diagnosis difficult during life, as the physical signs of the disease in the lungs 
are less obvious than where, as in the adult, the tuberculosis begins at the 
apex, and gives rise to consolidation and cavitation. The classification is 
also rendered more difficult when a number of organs in the body are 
attacked, as we have to speak of a general tuberculosis rather than tubercu- 
losis of the lungs, and some cases in which the lesions are widely distributed 
may be referred to diseases of the respiratory system or diseases of the 
alimentary canal. In the majority of cases of general tuberculosis the 
principal stress falls upon the lungs, mediastinal glands, mesenteric glands, 
peritoneum and intestine ; in a lesser degree upon the liver, spleen, and 
kidneys ; and in the last stage the membranes of the brain are frequently 
attacked. 

We have already discussed the subject of chronic tuberculosis of the lungs 
(p. 248) ; we will now speak of the acuter forms of general tuberculosis. 

Acute Miliary Tuberculosis. — Acute miliary tuberculosis is perhaps 
commoner in early life than it is in after years ; it occurs at all ages during 
childhood, though it is rare before the end of the second year. Like tuber- 
cular meningitis, with which it is often associated, it usually supervenes in 
children already tubercular, and occurs but rarely in children who up to the 
time of falling ill had been in robust health. There is usually a history oi 
more or less ill health for some time previous to the attack ; there is a 
history perhaps of whooping cough or measles some months before, which 
has left the child weak, and from which it has never really recovered. Some- 
times the symptoms of a tuberculosis of the lungs or abdomen are unmis- 
takably present, and then acuter symptoms supervene which mark the onset 
of the miliary form of the disease. 

Acute miliary tuberculosis occurs usually in two forms : the ( typhoid 
form,' so called because it is apt to simulate enteric fever, and the broncho- 
pneumonic form, in which the symptoms present are those o( acute pneu- 
monia, the latter being set up by the presence of miliary tubercle. 

Symptoms. — In the typhoid form the commencement is usually insidious, 
and is usually preceded by a period o\ ill health, timing which time the child 
has been noticed to waste, to he feverish at night, to cough, and not intre- 



374 



Tuberculosis 



quently to suffer from diarrhoea or pass slimy, unhealthy looking stools. The 
child is languid, irritable ; its appetite is very uncertain, and it cares but little 
for its toys. Often there are decided signs of intestinal catarrh ; the appe- 
tite is completely lost, the tongue is coated, and the abdomen distended. An 
examination of the chest may give no decided result, or only some rhonchi 
may be heard, and there may be no very decided cough. In this stage, if the 
symptoms are acute, the resemblance to an irregular attack of enteric fever 
is very close, especially if rose spots resembling those of typhoid are present, 
as is sometimes the case. The diagnosis is especially difficult in young 
children of three or four years of age, who are perhaps very irritable and 
resist any examination of the chest or abdomen, the difficulty being to dis- 
tinguish acute miliary tuberculosis from enteric or subacute intestinal catarrh 
with some patches of broncho-pneumonia. A careful and continuous record 
of the temperature is important ; the temperature should be taken morning, 

afternoon, and evening ; the 
variations are usually consider- 
able, sometimes varying from 
99 to 104 F., the highest being 
usually at 4 or 5 P.M. Too much 
stress, however, must not be 
laid on an intermittent tempera- 
ture with considerable flights, 
as in some children a patch 
of broncho-pneumonia without 
marked physical signs will be 
accompanied by a striking 
intermittent temperature, and, 
moreover, we have seen a case 
of miliary tuberculosis when the 
temperature only reached ioi - 5 
or 102 in the afternoon or 
evening. Enlargement and ten- 
derness of the spleen may be 
present in an early stage ; in some cases there is a marked feeling of hard- 
ness about it. In one of our cases rigors, with enlargement of the spleen and 
an intermittent temperature, suggested malaria, but the case turned out to be 
acute tuberculosis. 

Sooner or later, mostly in the course of a week or two, more characteristic 
symptoms declare themselves. There is a dry hacking cough, especially 
troublesome at night ; some crepitation or loose rales are heard at the apices, 
roots, or bases of the lungs, and not infrequently a sub-tympanitic or high- 
pitched note may be elicited on percussion, or perhaps there may be signs 
of fluid at one or both bases, with a pleuritic rub. In some cases there is 
marked dyspnoea, out of proportion to the pulse-rate and fever ; it is caused 
by the presence of miliary tubercles scattered through the lungs, with perhaps 
some disseminated emphysema or broncho-pneumonia. 

The hectic continues, and probably sooner or later, in the majority of 
cases, cerebral symptoms, due to meningitis or the softening of the brain 
which accompanies it, supervene. 




Fig. 63. — Miliary Tubercles of the Choroid ; slight optic 
neuritis. (From a drawing by P. H. Mules.) 



Miliary Tuberculosis 375 

One of the most important physical signs which may be present is 
that of miliary tubercles in the choroid ; the discovery of these may not 
infrequently clear up the diagnosis of a doubtful case. Unfortunately the 
restlessness and irritability of children suffering from tuberculosis often 
render it impossible to make a thorough ophthalmoscopic examination. 
The tubercles appear as small, rounded, yellowish bodies, scattered about the 
fundus ; one or more may be seen near the disc, but usually they are eccen- 
trically seated : five or six may often be counted. Often a branch of a 
retinal artery or a vein may be seen to cross in front of one. They appear 
very rapidly, being apparently formed in the course of a few days ; if there is 
tubercular meningitis, the disc may be swollen and indistinct. 

In a case recorded by Proebsting the detection of tubercular bacilli in the 
urine decided the diagnosis of a doubtful case in favour of miliary tuber- 
culosis. In this instance the miliary tuberculosis was secondary to chronic 
tuberculosis of the kidney. 

The duration of the disease varies, in some cases being short, often only 
three weeks ; in others, perhaps the majority, it is longer, the patient linger- 
ing for six or seven weeks. The supervention of tubercular meningitis or 
broncho-pneumonia quickly brings the end. 

The broncho -pneumonic form occurs most often in children from two 
to five years of age, and in the vast majority of cases is mistaken for an attack 
of acute broncho-pneumonia. There is often a history of measles or whooping 
cough shortly before the attack, and probably there has been a period of 
ill health with wasting. The symptoms are precisely those of acute broncho- 
pneumonia ; there is fever, dyspnoea ; rales or crepitation are heard over an 
extended area of lung, with more or less impaired resonance over a corre- 
sponding area. The disease usually runs its course in about ten days to two 
weeks, death resulting from exhaustion and more or less asphyxia. The 
family history or previous health may suggest tuberculosis in any given case, 
but no definite diagnosis of tubercular broncho-pneumonia can be made 
unless tubercles are seen in the choroid. The supervention of meningitis 
suggests tubercle, but a simple meningitis may accompany or follow broncho- 
pneumonia, especially in infants and young children. 

It must be borne in mind that acute or at least subacute general tuber- 
culosis, which is not of the miliary form, may occur disseminated through all 
the organs. A tuberculosis may run a course of six weeks to two months, 
accompanied by hectic and wasting, and. the principal lesions found post 
mortem are not miliary tubercles, though these may be present, but ragged 
cavities in the lungs, caseous bronchial and mesenteric glands, and caseous 
masses in the liver, spleen, and kidneys. In these cases the diagnosis may 
be difficult or impossible for the first few weeks, but careful examinations o\ 
the apices of the lungs will generally decide the question. 

Ih'ag?ioszs. — Acute miliary tuberculosis may be confounded with acute 
disseminated tuberculosis, in which the tubercular growth takes the form ot 
caseous nodules or other forms rather than the typical purely miliary form. 
The diagnosis is of very little importance except as regards the acuteness 
of the case, the miliary form being necessarily the most rapidly fatal. 
Both miliary tubercles and caseous infiltrations may be found in the same 
organ. Acute miliary tuberculosis may be mistaken for typhoid fever, 



3 7 6 Tn berculosis 

subacute intestinal catarrh, acute broncho-pneumonia, acute endocarditis, and 
pyaemia, and we may add influenza when the attack is prolonged, as it some- 
times is for many weeks. 

In making a diagnosis the family and personal history is of great im- 
portance ; if other children or older members of the family have died of 
tubercular disease, the probabilities in a doubtful case will naturally be in 
favour of tubercle ; but it must not be forgotten that apparently healthy 
children with a good family history will sometimes die of acute tuberculosis. 
A history of a recent attack of measles or whooping cough would be sug- 
gestive, but children with such a history may of course have typhoid or 
any other acute attack. There cannot be much difficulty in distinguishing a 
typical attack of typhoid fever from one of acute tuberculosis, but it may be 
quite impossible to make a diagnosis between an irregular and an erratic 
attack of typhoid and tuberculosis. In both diseases there may be some 
looseness of the bowels, abdominal distension, and intermittent fever ; in 
both the spleen may be enlarged. It is only by having the patient under ob- 
servation for some days, and frequently examining the chest, that a dia- 
gnosis can be made. A short hacking cough, hectic fever, great variations 
of temperature, dyspnoea out of proportion to the temperature, and crepita- 
tion heard in the chest, would favour the diagnosis of acute tuberculosis. 
Any cerebral symptoms, such as convulsions, squinting, drowsiness, mus- 
cular rigidity, or paresis suggesting meningitis, favour the diagnosis of 
tubercle. 

Some cases of broncho-pneumonia, where the distribution is patchy and 
the temperature markedly intermittent, closely simulate acute tuberculosis, 
and for a few days or a week a certain diagnosis cannot be arrived at. It 
is only perhaps when the pneumonia clears up, and the temperature tends 
to normal, that the suspicions of tuberculosis are relieved. 

In acute endocarditis the temperature is apt to be hectic, and in the 
absence of a bruit the diagnosis may be difficult. The presence of a bruit 
would necessarily prove the case to be almost certainly acute endocarditis, 
in spite of it resembling tubercle in other ways. 

Prognosis. — If the diagnosis of acute miliary tuberculosis can be definitely 
made, the prognosis cannot be otherwise than exceedingly grave. There 
can be little doubt that in a few cases, in an early stage, before the miliary 
tubercles are widely extended, recovery may ensue ; but when the tubercu- 
losis has become general very little hope indeed can be entertained. 

Morbid Anatomy. — The amount of emaciation present depends upon the 
chronicity of the case ; we have seen at the post-mortem cases in which there 
was a fair amount of subcutaneous fat in those who had died of acute miliary 
tuberculosis. On opening the chest, the lungs are found to be in a condition 
of deep inspiration, almost as if they had been injected with some fluid from 
the trachea, while miliary tubercles are seen on the surface or beneath the 
pleura. On section the lungs are found stuffed with miliary tubercles, of a 
grey colour and the size of millet seeds, usually so crowded that not a cubic 
inch in the whole lungs will be found free. They are mostly more crowded 
at the apex than at the base. Caseating or suppurating bronchial glands 
are almost certainly present. Frequently miliary tubercles are present in 
the glands. Miliary tubercles will be found crowded together in the liver, 



Scrofula and Tuberculosis 377 

spleen, kidneys, and serous membranes — frequently also in the choroid, 
and on the vessels at the base of the brain. 

In other less acute cases caseous masses and peribronchial tubercles may 
be found in the lungs, and may be associated with more or less miliary tuber- 
culosis. It is curious to note that many observers have failed to find the 
tubercular bacilli in miliary tubercles, and others have found granular masses 
suggestive of spores (Biedert, Ribbert, Malassez, and Vignal). 

Treatme?it. — If the diagnosis of acute miliary tuberculosis can be made 
with certainty, little can be hoped for from the administration of drugs. The 
treatment must in such cases be a treatment of symptoms. If the tempera- 
ture takes high excursions towards evening, quinine, antipyrin, or antifebrin 
may be given to anticipate the rise, and the patient packed or sponged with 
cold water to reduce it. The troublesome cough may be relieved by codeia 
jelly or minute doses of opium. The strength should be maintained by a 
liberal diet of beef tea, soups, port wine, Burgundy ; extract of malt and cod 
liver oil should also be given. Iodoform sometimes appears to be useful, 
though it can hardly be said to have any power in arresting the disease ; it 
may be given in powder with sugar in half- to two-grain doses. The com- 
bination of digitalis and bark has appeared to us to produce a temporary 
improvement, but any permanent change for the better cannot be looked 
for. 

Scrofula and Tuberculosis 

In this work the word ' scrofulous ' or ' strumous ' will seldom be found, 
since we believe that all scrofulous or strumous lesions are identical with 
tuberculosis, or rather that they are mere varieties or forms of tuberculosis. 
Just as in the exanthems and in gout, taking these as types of parasitic and 
non-parasitic diseases respectively, many vaiiations are found in the form 
and extent of the lesions, yet each presents some single feature or group of 
features characteristic of its species, so in the scrofulous or tuberculous 
affections there is much variation, as it were, in the habit of the disease ; yet 
the naked eye, or microscopic appearances, or the clinical history always 
reveals the unity of the affection. 1 

In certain children there is a characteristic tendency to inflammation 
from trivial causes ; this inflammation is apt to occur in, or rather pick out, 
the lymphatic tissues ; once aroused, it tends to spread, attacking often 
distant parts of the body. If its course is slow, the foci of disease tend to 
become caseous ; once started, the process seldom stops, or rather, though 
it may be arrested for a time, it is apt to be set going again by slight 
causes, even after long intervals of time. This tendency is found to run in 
families, some members showing one form of lesion, some another. At times 
different forms occur at different periods or even simultaneously in the same 
child. 

There is often, though by no means always, a characteristic appearance 
of the patient, but it is quite common to find the disease under discussion 
in children not at all answering to either description. The types usually 
described are: 1. Sanguine type the child is tall, slight, graceful, with 
small fine limbs, clear skin, and fine silk) hair; the intelligence is bright 

1 Vide also Charcot, Med, Chron, October 1884, Kbnig, ibid. November 1884. 



37 8 Tuberculosis 

2. Phlegmatic type— the child is short and thick-set, with coarse skin and 
limbs, thick features, and a dull, flabby aspect. 3. 'Pretty strumous 5 type 
— which is intermediate between the two former. 1 

The evidence of identity of scrofula and tubercle from the clinical history 
is best seen in two ways : first, that in a given number of cases where either 
condition is present, inquiry will show a large proportion in which there is 
a history of lesions in other members of the family,'- these lesions being 
■often, as it were, crossed ; thus the child with disease of its hip has a brother 
with chronically enlarged cervical glands, and the father died of acute 
phthisis. Why should vve call the father tuberculous and the children ' scro- 
fulous ' ? Or again, the child with a ' pulpy ' knee may develop caries of the 
spine and then die with grey tubercles in its lungs and abdominal viscera, 
or suddenly be attacked with tubercular meningitis. Or again, a child with 
a. 'scrofulous' joint disease, after some violent manipulation, perhaps forcible 
straightening of a flexed knee or imperfect removal of diseased tissue, rapidly 
■develops tuberculosis, having had no sign of it before. There is strong 
reason to believe that in some of these cases there is direct tuberculous 
embolism or general rapid distribution of tuberculous infective material 
throughout the body. Take one more illustration : a child with ' strumous 
■dactylitis ' develops along the course of the lymphatics of its arm multiple 
' strumous nodes,' and finally suppurating glands above the elbow and in the 
axilla ; these would be called scrofulous abscesses and scrofulous glands, yet 
they are simply tuberculous emboli from the finger. Treves looks upon 
scrofula as a phase of tubercle ; the phthisical parent has scrofulous chil- 
dren. He found a history of phthisis in thirty-eight out of sixty-five cases of 
scrofula. A child begotten of parents, one of whom, perhaps especially the 
father, is at the time actively phthisical, is certainly exceedingly likely to be 
tuberculous. This we have seen most markedly. Tuberculosis may even 
occur congenitally. Dr. Morgan records a case of ' scrofulous sores ' on the 
head and nates of a two-months foetus {Path. Soc. Trans, vol. xviii.) ; and 
Dreschfeld has described a tubercular testis in a newly born infant. 

Anatomically, in the subjects of 'acute miliary tuberculosis' we find 
always, or nearly so, somewhere in the body, caseous foci which if seen alone 
-would be called scrofulous. Examined microscopically, the evidences of 
chronic inflammatory change undergoing degeneration — the characteristic 
tubercle, the giant cell, the tubercle bacillus— are all found in almost all the 
lesions classed as scrofulous, though much less abundantly in some tissues, 
such as bone, than in others. It is then wiser on all grounds to consider all 
scrofulous and strumous diseases as tuberculous, and therefore to be on our 
guard against the onset of tuberculosis in vital parts ; for instance, the 
common chronic osteomyelitis of the finger may be the only discoverable 
lesion in an apparently robust child, yet that child is infected with tubercu- 
losis, and may at any time develop other foci, and may die of visceral 
tubercle ; hence none of these diseases should be looked upon as trivial. It 
must, however, be remembered that there is much evidence to show that 
there is some antagonism between local 'scrofulous' lesions and general 
visceral tuberculosis, or rather that so long as the local lesion is unrepaired 

1 Vide Treves on Scrofula and Gland Diseases. 

- Vide chap, on Joint Diseases for figures on this point. 



Tubercular Adenitis 379 

the internal organs escape, while recovery from the local disease may be 
followed by general infection. This has given rise to the view that the local 
•disease acts as a sort of safety valve. It is probable that the truth is that 
so long as the local lesion remains quiescent, or, as it were, encapsuled, no 
general infection takes place, but if from any cause the tuberculous material 
gains access to the neighbouring vessels or lymphatics, a rapid dissemination 
of the tubercle is brought about. The disease often lies dormant for years 
or for a long lifetime, and the patient may never show any further sign of 
tuberculosis ; we must therefore not condemn all these children as hope- 
lessly tuberculous. Indeed the tendency to develop tubercular foci often 
dies out after a time, and the child becomes quite sound. Such children 
should be taken care of more watchfully than others need be, and no source 
of irritation, however slight, be allowed to continue ; carious teeth, little 
patches of herpes or eczema, slight injuries, and so on, should be seen to at 
once, lest chronic inflammation should ensue and a tubercular nidus be es- 
tablished. The diet in all such cases should be especially nourishing, and 
the usual remedies of cod liver oil as an article of food rather than a medi- 
cine, iodine in some form, iron, and, above all, sea air, should be provided 
where practicable. In the richer class of patients such children should go 
to school by the seaside. 

Details of management of individual lesions will be found in the various 
special chapters. 

Tubercular Adenitis. — As already pointed out, the lymphatic tissues 
are those most commonly and most extensively attacked by tuberculosis, 1 and 
lymphadenitis is commoner than lymphangitis, since any solid material 
taken into the lymphatic vessels is apt to be arrested in the adjacent gland. 
The thick lips and nose and the red patches and eczematous eruptions of 
children are, as pointed out by Curnow, ' reticular lymphangitis.' Under 
certain circumstances chilblains are probably a similar condition. Irritating 
matters passing up the lymph stream are not, however, by any means always 
arrested at the nearest glands, partly because the course of the lymphatics 
varies, and the most commonly affected glands may be avoided by a bye- 
route and those further on attacked, and partly because the material pro- 
bably may sometimes pass through one gland and involve the next, or after 
■one gland has become inflamed it may become a source of infection to the 
next in the chain. Hence search should be made for sources of irritation out 
•of the usual path if none are found in the common positions. If one obvious 
enlarged gland exists the presence of others should always be suspected. 
The first thing, then, when a child is brought with an enlarged lymphatic 
gland, is to examine the whole area draining to that gland for some source 
of irritation, past or present : this will be facilitated by the following table, 
where the principal lymphatic glands and their collecting areas are given. 9 

1 Greig Smith has remarked upon the frequency oi~ lesions oi ' red marrow ' as an illus- 
tration of its lymphatic affinities. 

2 Curnow, Lancet, 1S79. Sappey, Anat-Phys. Path, des Vaisstauy .' 
Paris, 1874. 



3 8o 



Tuberculosis 



Table showing the Distribution of the Lymphatic Glands 
and their drainage areas. 1 



Head and Neck. 



Glands. 

Suboccipital . 

Mastoid. . . . . 

Parotid . . . . . 

Submaxillary 

Suprahyoid or submental 

Superficial cervical 

(lying beneath platysma) 
Relro-pharyngeal . 

Deep cervical : 

Upper set along carotid 
sheath : 



Drainage Area. 



Lower set in supra- 
clavicular fossae : 



Supracondyloid • 
Axillary " 



)■ drain posterior half of head. 
j 
drain anterior half of head, orbits, nose, 

upper jaw, upper part of pharynx, 
drain the lower gums, lower part of face, 

and front of mouth and tongue, 
drain anterior part of tongue, chin, and 

lower lip. 
drain external ear, side of head, and neck 
and face. 
. drain nasal fossae and pharynx (upper 
part). 

drain mouth, tonsils, palate, lower part ot 
pharynx, larynx, posterior part of tongue, 
nasal fossae, parotid and submaxillary 
glands, interior of skull, and deep parts 
of head and neck. 

drain upper set of lymph glands, lower 
part of neck, and join axillary and 
mediastinal glands. 

Upper Extremity. 

drain three inner fingers. 

drain upper extremity, dorsal and scapular 

regions, front and sides of trunk and 

breast. 



Lower Extremity. 

Anterior tibial a?td popliteal : drain the deep lymphatics of the leg, and 

receive some vessels from the skin of the 
leg and foot, chiefly the outer side. 
I?iguinal : 

Femoral set (superficial) . drain superficial vessels of lower limb and 

partly of buttock and genitals, also 
. t perinaeum. 

Horizontal set (superficial) : drain abdomen below umbilicus, buttock 

and genitals. 

The deep vessels of the lower limb 
go to the deep glands along the femoral 
vein. 



1 Mainly from Curnow and Treves. 

2 Occasionally there are glands in the bend of the elbow. 



Tubercular Adenitis 381 

Abdomen. 

Glands. Drainage Area. 

Iliac drain the pelvic viscera and the deep vessels 

of the genitals partly. 

Lumbar drain all the lower glands, uterus, testes, 

ovaries, kidneys. 

Sacral drain the rectum. 

Roughly, the umbilicus is the water- 
shed draining to the axilla and groin, 
but the vessels cross and overlap both 
vertically and horizontally. 

Perhaps the most commonly enlarged glands are those of the neck and 
submaxillary regions, parts obviously much exposed to irritation ; thus eczema 
of the scalp, the irritation of pediculi &c. give rise to enlargement of the 
occipital and upper cervical glands ; herpes about the nose to irritation of the 
parotid or submental glands ; while carious teeth, ulceration of the gums, and 
so on, affect the submaxillary and cervical groups. The upper set of cervical 
glands are found enlarged from irritation of the meatus externus in cases of 
otorrhcea and in cases of tonsillitis. As already mentioned, a lymph gland 
overlies the tonsil, and is usually enlarged in affections of that structure, 
which is not perceptible from the neck under ordinary circumstances. Treves 
points out that those glands which drain areas rich in lymphoid tissue 
are the ones most commonly enlarged ; hence the cervical, bronchial, and 
mesenteric groups are those most often affected. 

The enlargement of lymphatic glands is sometimes acute at first, and they 
are then tender and painful ; in other instances the swelling is chronic and 
painless from the beginning. The glands form hard, rounded, or oval masses 
freely movable in the deeper tissues and beneath the skin, unless there has 
been cellulitis around the gland (periglandular inflammation). In chronic 
cases the overlying skin is natural, and usually several glands can be felt ; 
often a chain of them, varying in size from a pea to a walnut, can be traced. A 
mere transitory irritation may start inflammation in a gland, and then, though 
the local source has entirely disappeared, the enlargement may persist and 
other glands in the chain be affected, as already described ; hence we must not 
conclude that there has been no primary source of irritation, and that the 
glandular affection is spontaneous because we can find no cause for the 
enlargement. Cold, or some trifling injury, a sore upon the skin or mucous 
surface, soon healed and forgotten, or perhaps never noticed, is sufficient to 
set up chronic tubercular adenitis, which may spread and last for months 
or years. Primary adenitis not due to absorption is probably very rave. 
Treves points out that cervical adenitis may be caused by extension from 
within the chest or other distant parts. 

After a time, unless the process subsides, the glands become very hard, 
and by their size and number give rise to great disfigurement and occasion- 
ally to more serious trouble. Goode, o\ Cincinnati, lias recorded a case ot 
death in a baby five months old from pressure of a caseous gland upon the 
carotid sheath. These swellings arc seldom painful ; after a time one or more 
patches of softening may appear, and. is the processgoes on the skin becomes 



382 Tuberculosis 

red or livid, and finally thinned and perforated ; thin watery, sero-purulent 
fluid with flakes of lymph and cheesy matter then escape, more rarely 
fairly healthy-looking pus ; occasionally the discharge is clear glairy fluid, like 
the contents of some mucous cysts, but in such cases there is almost always 
some more purulent matter at the bottom of the cavity, which can De- 
squeezed out. The discharge may go on indefinitely, and an ulcer is formed 
which has little tendency to heal, and is bounded by thin, livid, undermined, 
unhealthy edges. If healing does take place the scar is puckered and 
unsightly, often with bridges or tags of thin insensitive skin hanging from 
it, and little black spots due to accumulation of dirt and secretion in the 
hollows of the scar. Such is the condition seen in an old ' scrofulous neck. 5 
If such a gland as that above mentioned is examined in the early stages 
of the process, it will be found firmer and paler than in health, but not other- 
wise obviously altered ; a little later patches of yellow cheesy material of 
various sizes will be found scattered through the gland, sometimes in one or 
two large foci, at other times in numerous small ones ; the capsule of the 
gland is thickened. Later still, these caseous foci break down, the greater 
part of the gland tissue is destroyed, and the gland itself becomes converted 
into a bag of cheesy or flaky pus and detritus, with walls composed of the- 
capsule and more or less of the gland tissue remaining unsoftened. It 
happens, however, sometimes that, instead of the gland breaking down and 
softening in the centre, suppuration takes place in the cellular tissue round 
it— periglandular abscess ; this burrows round the gland and isolates it, so- 
that there is a solid mass of gland tissue lying in an abscess cavity, and per- 
haps attached to the surrounding tissues only by the structures passing to its 
hilus. In this last case, when the skin gives way, instead of a deep ulcer 
there is seen a round pinkish or yellowish-white mass projecting from the- 
middle of a circular sore, the edges of which are loose, undermined, thin, and 
livid ; there is often but little discharge, and no tendency to heal, or, indeed,, 
to alter much one way or the other. Where many glands are enlarged, all 
stages, from the first primary enlargement to the last-named condition, may- 
be seen at once, and sometimes the whole neck from ear to ear is marked by- 
ulcers, scars, and enlarged glands in various stages. In such cases it will 
usually be found that many teeth in one or both jaws are carious, and acting 
as sources of irritation. 

It must, of course, be remembered that all such glands do not go on to- 
suppuration, and perhaps in children there is more chance of resolution 
than in adults ; however, the majority do suppurate if they remain enlarged 
for more than a short time. 

Coexisting with the glandular abscesses and sores will often be found 
superficial ulcers, round or irregular in form, often scabbed over, and only dis- 
charging at times. The edges of the sores are usually unhealthy and under- 
mined, and their bases glazed or covered with coarse, unhealthy granulations 
and caseous detritus ; some of the ulcers are no doubt caused by the dis- 
charge of broken-down glands ; in these a small aperture will be found 
leading down to the underlying gland ; others are probably due to abscesses 
beginning in lymphatic vessels, due to tubercular lymphatic emboli, or rather 
thrombi — tubercular lymphangitis, 'strumous nodes;' others again probably 
to local cutaneous tuberculosis. 



Tubercular Adenitis 383 

Diagnosis. — Tuberculous adenitis and ulcers may be mistaken for 
syphilitic ulceration, which gives rise to very similar appearances, except 
that ulceration predominates over the glandular enlargement. It must be 
remembered that congenital syphilis and tuberculosis may coexist. The 
presence of other evidences of syphilis will nearly always clear up a doubt. 

Simple acute adenitis is recognised by its short history and by the pain 
and great tenderness of the part, as well as by the presence of an acute source 
of irritation, such as an alveolar abscess or acute tonsillitis, and by the fact 
that usually only one gland is enlarged, though several may be tender. 

Simple non-tubercular chronic adenitis may occur as the result of acute- 
inflammation, but this usually rapidly subsides under treatment and affects 
but one gland ; if the affection is obstinate, suspicion of its tuberculous nature 
should be aroused. 

Lupous ulcers are the only other condition likely to be mistaken, and as 




Fig. 64. — Tubercular Ulceration of the Skin of the Foot, showing imperfectly formed scar-tissue 
overlying the tuberculous granulations. A form of so-called Lupus hypertrophicus. 

these are also tuberculous, the mistake is of little importance. The presence 
of well-defined lupous tubercles is the distinguishing feature. 

Tuberculous abscess of the skin, 'scrofuloderma,' 'scrofulous gumma,' and 
' strumous node,' are the names applied to small tuberculous foci probably 
in the lymphatics which, at first hard and solid, usually break down, though 
sometimes they are absorbed. These little swellings are often found in the 
thickness of the skin itself about the limbs, face, or trunk. Occasionally the 
mischief spreads, and a large cold abscess or tuberculous ulcer may result. 

Chronic tonsillar hypertrophy is considered by Treves to be 'almost 
pathognomonic of scrofula'; though very common in tubercular children, we 
think it is often met with in those who show no other signs ot tuberculosis ; 
it may occur during the first lew months o( life. Infantile Icucorrlnva and 
certain vulvar ulcers have been supposed to be tuberculous ; no doubt many 
cases of aural suppuration are so. 



3 84 Tuberculosis 

Treatment. — The treatment of tuberculous adenitis consists at first in care- 
fully removing all sources of irritation ; carious teeth, enlarged tonsils, patches 
of eczema, nasal catarrh, otorrhcea, chafed heels, and so on, should all re- 
ceive attention according to the seat of the enlarged glands and the source 
of the trouble. Next, the general measures of diet and health already men- 
tioned must be carried out. As to the local treatment of the glands them- 
selves, this must be managed according to the stages of the disease. (1 In 
the early stage, before caseous foci have appeared, after removal of the source 
of irritation, the glands should be left quite alone, in the hope of their sub- 
siding. If no improvement takes place in a fortnight, the glands should 
have a piece of unguentum plumbi iodidi or unguentum hydrargyri of the 
size of a small pea gently rubbed over them night and morning. Painting 
with tincture of iodine we do not approve of; it is far more likely to increase 
the irritation of the glands than to lessen it. Should the enlargement not 
yield to these means, and should the stage of caseation, known by a du- 
ration of two or three months with considerable enlargement and much 
hardening of the glands, be reached, the best treatment is to cut down upon 
and shell out the glands entire — a very easy operation at this stage where 
only one or two glands are involved, a much more difficult and sometimes 
impossible one where many glands in a chain are enlarged and there is peri- 
glandular inflammation. In favourable cases an incision through the skin 
and fascia, and then through the sheath of the gland, followed by pressure at 
each side with the fingers, will render enucleation of the mass quite easy. 
All the glands felt to be enlarged should be removed, all bleeding stopped, 
and the edges carefully brought together, no drainage being used if the 
wound is clean. The resulting scar is slight, and much less unsightly than 
that left in cases where suppuration has gone on. The plan of puncture 
with the thermo-cautery we have not found satisfactory ; it is apt to leave 
intractable sinuses. 

In the next stage, when the gland has softened down, if there has been 
no periglandular mischief, it may be still possible to dissect the mass out, and, 
if so. this is the quickest and best method ; it is, however, impracticable if the 
glands have become matted to the surrounding tissues : in such cases the 
.abscess should be opened by an incision about half an inch in length ; a long- 
incision is not necessary, but it must be sufficient for free manipulation and 
drainage. After opening the abscess a Yolkmann's spoon is passed in, and all 
the gland tissue carefully and thoroughly scraped away : if any is left the 
wound will not heal, but the part remaining will caseate, break down, and keep 
open a sinus ; hence, if all the gland cannot be scraped away, the most 
satisfactory plan is to enlarge the incision and dissect out the remaining parts. 
Some surgeons recommend a small opening, and leaving the abscess to slowly 
drain. Injection of chronic glandular abscesses with a solution of iodoform in 
ether is well worth a trial : we have seen them completely disappear under 
this treatment. Where, as often happens, two or more glands near, but not 
fused with, one another have broken down, the further ones may often be 
reached, as pointed out by Mr. Teale, by thrusting the spoon through the 
adjacent walls and thus emptying all the cavities through one opening. 
The wound should be well dusted with iodoform and drainage provided for. 
When the abscess has already burst and left a sinus, the same treatment 



Treatment of Tuberculous Adenitis 385 

should be adopted. Where ulcers have formed with undermined edges 
these should be scraped or clipped away flush with the healthy skin : a 
large wound may thus be sometimes left where there was but a small opening 
before, but the ultimate result will be a much less unsightly scar, as well as 
more rapid healing, if this devitalised skin is removed ; all the unsightly 
tags and bridges will be thus avoided. 

Where there is a protruding isolated gland in the middle of a sore, if it 
is soft it may be scraped away ; if not, we have found Golding-Bird's little 
electrolytic caustic apparatus serviceable. The silver plate is fastened by 
a strip of strapping on to a neighbouring sore if there is one, or, if not, 
on to a surface made raw by a blister, and the copper wire is bent so 
that the zinc arrow can be plunged into the middle of the gland ; a strip of 
strapping fixes the arrow, and a bandage is applied over all. The apparatus 
is left on for forty-eight hours, or more in some cases : at the end of that time 
the gland will look yellow and dry ; the apparatus is then removed and a 
hot boric lotion dressing applied for twenty-four hours, when the gland is 
usually found to come away ; if more glands remain, the apparatus may be 
reapplied. In this method there is a deposit of nascent chloride of zinc in 
the gland which quite painlessly and rapidly destroys it, and we have never 
seen any tendency to extensive sloughing, nor anything except good results, 
from this mode of treatment in suitable cases ; it is, of course, only valuable 
-where objection is made to removal of the gland by operation. 

Mr. Teale has pointed out that where one superficial gland is enlarged 
and suppurating there is usually another, lying beneath the deeper fascia, and 
that, unless this is cleared out, the source of discharge is not removed and 
the sinus will not heal. It is necessary to look carefully sometimes to find 
the channel leading to the deep gland, but it is there and must be followed by 
the spoon, and the second mass removed. Mr. Teale uses a special dilator 
to stretch the sinus, but a dressing or sinus forceps will usually be found to 
answer all purposes. 

Iodoform is the best dressing to apply to these sores at first, and later on 
they do very well with iodide of lead ointment. 

Where several sinuses are left in the neck it is a good plan to use, as 
advised by Treves, a gutta-percha or leather stock to keep the parts at rest 
(the sawdust collar will be found useful for this purpose), and in other parts 
of the body efficient pressure by pads and bandages or by a truss is often 
•useful. 

Where depressed scars remain after gland diseases Adams's or Reeves's 
operations may be employed. The former loosens the skin by subcutaneous 
division of the scar, and by daily manipulation keeps it from becoming 
reattached till the hollow is filled up. Reeves props up the depressed skin 
upon a wire passed beneath it, which may be left in permanently, or removed 
if it sets up irritation. We have had a good result from the latter method. 
A far better plan, however, in most cases is to cleanly excise the whole 
scar, and bring the cd^es of sound skin accurately together by means oi 
sutures ; thus a linear cicatrix takes the place of the irregular puckered or 
depressed scar. 

Acute non-tubercular glandular abscesses in parts of the body other than 
the neck are often met with, anil require treatment on general principles. 

C C 



3 86 Tuberculosis 

Where the popliteal or inguinal glands are involved the limb should be kept 
extended and fixed to a splint. Suppurating popliteal glands are apt to 
give rise to serious trouble ; the matter tends to burrow far up the limb. In 
one case we had to amputate the thigh where an abscess, beginning in the 
popliteal lymphatics as the result of an irritated chilblain, eroded the popli- 
teal artery, opened into the knee joint, and burrowed up to the pelvis. 

Acute adenitis, if seen before suppuration has occurred, will usually sub- 
side if the source of irritation is removed and the part well fomented after 
smearing it with extract of belladonna. If pus forms it should be let out as 
soon as possible. 

Chronic Abscess. — Chronic abscesses may now be dealt with much 
more speedily and satisfactorily than in former times. In all cases, of course, 
the source of irritation should be looked for and if possible removed ; unless 
this is done success cannot be reasonably expected. 

In some instances, if the contents of the abscess are drawn off through 
an aspirator and an emulsion of iodoform in glycerine injected (from 5j- — 3ss. 
being a usual quantity to use), the abscess will slowly subside. This 
method is not, however, likely to succeed where any irritating or much 
caseous material is present. In such cases the abscess should be freely 
opened and its contents and whole lining most carefully scraped and rubbed 
away ; this part of the proceeding must be done thoroughly or the operation 
will fail. 

The abscess cavity should then be well washed out with perchloride 
of mercury lotion of strength I in 3,000, and, after being thoroughly dried 
out, either a mixture of iodoform and boric acid in equal parts should be 
dusted in, or some of the iodoform emulsion injected. The wound is then to 
be carefully and completely sewed up, all excess of fluid being squeezed out 
just before the dressings are applied. The dressings should consist of wood- 
wool wadding or some similar substance packed carefully on over a layer of 
wet gauze. . The dressing should be so applied that the walls of the cavity 
are accurately kept in contact and firm pressure made. In successful cases- 
the wound need not be disturbed for ten days or a fortnight, when it will be 
found soundly healed. If, as sometimes happens, the wound heals but the 
abscess refills, either the source of irritation at a distance has not been 
removed, or the cleaning out of the cavity has not been complete ; the 
operation should be repeated, and will probably be successful. In cleaning 
out the cavity it is useful to twist an artificial sponge tightly into all parts 
of the cavity and screw it round so as to entangle and wipe out all caseous 
material. 

Deep Cervical Cellulitis — Angina Ludovici — is a very serious affection; 
the mischief apparently begins as a periglandular inflammation, goes on to 
sloughing, and may perforate the cheek. There is at first a brawny infiltration 
of the submaxillary region ; the skin in milder cases is pale and marked by 
turgid veins ; in the more severe and acute cases, however, a deep brownish- 
red discoloration appears. The whole neck may be involved, and there is 
great swelling, with marked prostration, and sometimes dyspnoea or dysphagia 
from mechanical pressure. The disease is met with usually in children under 
three years of age, often in infants, and occurs under similar conditions to 
cancrum oris. Early and free incision is urgently required ; usually much 



General Surgical Tuberculosis 387 

foul brown serum or sero-pus escapes. Free stimulation and abundant 
nourishment are required, with removal from insanitary surroundings. 
The mortality of these cases, which much resemble those of scarlatinal 
cellulitis, is considerable. 

Case. — Female, age i year 9 months ; neck swollen a fortnight ago ; on admission, 
right side of neck tense, hard, brownish-red ; swelling reaches to clavicle ; swelling incised, 
serum only escaped ; much fever before incision ; skin sloughed ireely, and pneumonia 
set in, child dying on seventh day. 

Post-mortem. — Abscesses in lungs and sanguineous pleuritic effusion. 



General Surgical Tuberculosis 

A condition perhaps best described as 'general surgical tuberculosis' is 
common, the term being applied to those cases where there are tuberculous 
foci scattered far and wide over the body in various tissues. Thus children 
are seen with ulcers of the hands, abscesses or still unsoftened nodes along 
the course of the lymphatics of the fore-arm, and a supracondylar gland 
enlarged : perhaps a patch of ulceration on the cheek and submaxillary 
adenitis, phlyctenular ophthalmia, tubercular osteo-myelitis of one tibia, with 
disease of the tarsus on the opposite side, and so on. Such a combination 
is by no means a rarity : not very long ago we had in the hospital a boy 
with disease of one hip, one elbow, one ankle, and sacro-iliac disease ; in 
another the shoulder, ankle, and wrist were all excised for tuberculous 
disease. Such cases, if they are neglected, gradually lose strength and 
sink, but good food and sea air, combined with removal of the disease as 
soon as it is evident that spontaneous repair is impossible, will often work 
wonders. 

Operation should be deferred till it is seen- what nature can do ; but if 
with the improvement in the child's health no progress is made locally, or if 
there is pain or much discharge, the affected tissues — bones, joints, &c. — 
should be removed. We have often been surprised at the rapid and com- 
plete repair effected in such children, and even in the cases looking most 
desperate locally, resections or scrapings will sometimes succeed and am- 
putations prove unnecessary. 1 But in all these children relapses will occur 
if the health is again allowed to fail from bad food and hygiene. 

As regards details of local treatment in such cases, we find iodoform 
mixed with an equal quantity of boric acid and dusted on, or iodoform 
ointment, the best application. Where operation is called for, all dead and 
carious bone should be excised or scraped and gouged away, all soft caseous 
and pulpy granulation tissue removed, and undermined livid edges oi skin 
clipped off. The incisions may sometimes be closed with sutures and 
primary union obtained; where possible this should be attempted. If, 
however, the destruction of the skin renders union impossible, the wounds 
should be left freely open ; they often heal with great rapidity and leave but 
little deformity. Amputation is sometimes required for tarsal and knee joint 
disease, but in the upper extremity we have never seen <7 case thai 
it, except in the fingers, though some have at fust appealed hopeless enough. 
Caries of the spine in such children is the most serious condition, from its 

1 See, however, chapter on Hone and Joint Diseases, 

C v j 



388 Diabetes 



inaccessible position ; but even this is not hopeless. It is not so common as 
might be expected to find visceral tubercle in these patients, and this is 
probably one of the reasons why they have been called scrofulous and not 
classed as tubercular. The term 'surgical tuberculosis ' has been used to 
imply that operative treatment can do much for them, and that the lesions 
are external. The following case illustrates this. 

Surgical Tuberculosis. — Edward C, aged 9 years 6 months. Admitted November 7, 
1885. No tubercular history. Always healthy till two years ago, when an abscess 
appeared at the back of the leg, and others subsequently elsewhere ; they have continued 
to discharge since. Four months ago he fell upon the elbow, and an abscess formed, 
which was opened, and has been discharging since ; joint stiff. On admission, a sinus 
over the outer end of the left clavicle, leading to bare bone. Abscesses and enlarged glands 
in the neck ; a sinus on the left buttock and another over the inner condyle of the left 
humerus. 26th, several small loose sequestra removed from the cavity in the clavicle, close 
to and involving the acromio-clavicular joint ; abscess in neck scraped out and a deep 
gland beneath the fascia scooped away ; some caseous bone scraped from inner condyle 
of humerus. 27th, much pain in elbow, which subsided partially by the 29th ; he did fairly 
well, and was sent out on December it with all the ulcers &c. doing well, except the 
elbow, which remained swollen and tender. Such cases are very frequently met with. 



Diabetes Meilitus 

Though diabetes is much less common in children than in young adults, 
it cannot be said to be rare, as Gerhardt has recorded 1 1 1 cases at various 
ages, from six months to fifteen years. Cases have been observed in infants 
at the breast, though the diagnosis in such may be open to doubt on account 
of the difficulty of obtaining the urine, and of the uncertainty of detecting 
small quantities of sugar in the urine. Little can be said about the etiology 
of these cases ; a history of diabetes in the family may, however, often be 
obtained. Thus, in a family we are acquainted with two uncles died of 
diabetes, and two children, brother and sister, aged 14^ years and 3^ years. 
Another sister of 6h years has sugar occasionally in the urine. 

The symptoms noted are those which are present in adults. There is 
the harsh dry skin, red tongue, marked thirst, and voracious appetite. There 
is often incontinence of urine on account of the large quantities passed. The 
specific gravity of the urine is high, 1030 to 1040 or more, and perhaps 5 per 
cent. or even 10 per cent, of sugar may be found. The child usually wastes, 
especially if not carefully treated, and is apt to contract a fatal pneumonia. 
Tuberculosis or chronic phthisis may supervene as in adults. Diabetic coma 
has also been observed by several authors, and one has come under our own 
observation, though perhaps it is not so common as it is in the case of young 
adults. The symptoms commence with headache, dry tongue, and dyspnoea, 
followed by coma. It is well to bear in mind the possibility of being called 
to see a child who h3S rapidly passed into a state of coma without diabetes 
having been suspected. 

The prognosis is mostly unfavourable, though cases are recorded which 
made apparently a permanent recovery. In the fatal cases the duration 
varies from a few weeks to a year. 

Treatment. — All starch-containing foods and sugar should be forbidden, 
gluten bread and saccharin being substituted. Milk in moderate quantities 



Diabetes Insipidus 389 

or cream may usually be allowed, as children are much more dependent 
upon milk as a food than are adults. Beef tea, soups, fish, chicken, and 
butcher's meat, with gluten bread and green vegetables, will chiefly form the 
diet. Much difficulty is often experienced in keeping children to a rigid 
diet, as they hanker after bread-and-butter or puddings. With regard to 
drugs, codeia (gr. £ to gr. £) or opium should be given, while the bowels 
are carefully regulated with Carlsbad salts or Rubinat water. Great care 
should be exercised to prevent the child catching cold or any of the zymotic 
diseases, since bronchitis, whooping cough, or scarlet fever is almost certain 
to unfavourably affect the course of the disease. 

Polyuria — Diabetes Insipidus 

The etiology of this condition is for the most part quite unknown, and it 
probably owns a variety of causes. Cases of brain disease, of contracted 
kidney, tuberculous kidney, and of functional diseases of the alimentary 
canal may be accompanied by polyuria. In the majority of cases no cause 
can be assigned, and we are obliged to speak of such as idiopathic, much in 
the same way as we speak of idiopathic anaemia. In a large class of cases 
polyuria is temporary only. Children, often girls between three and six 
years, are noticed to wet their beds, or make water in the day time far more 
frequently than they have been accustomed to. In the same way boys will 
wet their trousers frequently during the day when it was thought that they 
had grown sufficiently old to have learnt proper habits. An examination in 
such cases will probably show no abnormal constituent of the urine, but 
that it is of low specific gravity, perhaps 1005 to 1010, and passed in larger 
amount than usual. Possibly there may be a trace of albumen. In the 
majority of cases this condition will be found to depend upon digestive de- 
rangements or improper feeding ; it appears to be a reflex irritation of the 
kidneys, the source of irritation being in the intestine, the presence of an 
intestinal catarrh being the cause. Possibly also the deposition of uric acid 
salts in the kidney may be the cause of a large quantity of watery urine 
being secreted. The presence of thread worms or round worms in the 
intestine or rectum also appears at times to produce polyuria. In those rare 
instances of contracted kidney occurring in childhood large quantities of 
urine are sometimes passed : in such cases the specific gravity is low, but 
there will usually be some albumen. 

In those cases to which the name of ' Diabetes insipidus' is usually 
applied there is intense thirst, and large quantities of pale urine with a 
specific gravity of 1002 to 1005 are passed. A girl of %\ years under our care. 
who had suffered for some six months, drank as much as ten quarts in 
twenty-four hours, and passed a proportionately large quantity of water. 
When restricted to ten pints of fluid daily, she would in the night crawl 
under the beds to the bath-room to obtain water, or surreptitiously drink her 
own urine. Such patients have dry, rough skins, are anaemic, and of irritable 
temper. The course of such eases is exceedingly chronic, and post- morti 
are seldom obtained. 

Treatment. — The treatment must depend on the cause. If simply reflex, 
dependent upon intestinal irritation, a calomel purge may be given and a 



390 Rheumatism 

carefully restricted diet prescribed. In confirmed cases of Diabetes insipidus 
various drugs have been tried : opium, strychnine, valerian, and ergot usually 
fail ; in our own case no drug seemed to check the secretion of urine in the 
least — a temporary improvement took place during an intercurrent attack of 
tonsillitis. In all cases the patient should be warmly dressed and protected 
from cold, as a chill has the effect of checking the perspiration and so in- 
creasing the secretion of urine. 

Rheumatism 

Rheumatism, either in its acute or chronic form, is not common during 
the first four or five years of childhood ; it is commoner after this age, but 
typical attacks of acute rheumatism occur less often in children than in 
young adults. Concerning the etiology and pathology of rheumatism but 
little need be said : hereditary influences, the effects of cold and damp, the 
retention of waste products in the blood, and the poison of scarlet fever, seem 
in greater or less degree to predispose to or excite an attack of rheumatism. 
Symptoms. — These in older children closely resemble those seen in 
adults, except that the attacks can rarely be called acute, but belong rather 
to the category of subacute, the attacks being less severe and of shorter 
duration. The illness sometimes begins with vomiting and chilliness, but 
more often the first thing complained of is pain and tenderness in the larger 
joints, which may become red and more or less swollen. The commonest 
joints to be affected are the larger ones, such as the knees, ankles, hips, wrists, 
and shoulders ; these are rarely all affected at the same time or indeed in 
the same attack ; much more commonly one or both knees are distended 
with fluid, while subsequently a wrist or an ankle becomes red. tender, 
and useless. The joints of the cervical vertebrae are often affected, and 
occasionally some of the smaller joints, such as the fingers. There is not 
often much fever, the temperature rarely exceeding io2 = . Usually there is 
not much sweating, the joints quickly recover themselves, and the pain and 
immobility disappear in a few days. Sometimes the only evidence of a 
rheumatic attack is a slight redness and tenderness about a single joint. It 
is the exceeding mildness of these attacks as well as the want of intelligence 
to localise their pains that make attacks of rheumatism readily overlooked 
in young children. A crying out when disturbed, with a certain amount of 
paresis or immobility about a limb, may be all there is to indicate an attack 
of rheumatism, which, mild as it may be. is yet perhaps accompanied by 
endocarditis which may inflict a life-long injury. 

Distinct attacks, however, may be noted in young children, of which the 
following, a patient seen with Dr. Earle, may be taken as an example : 

Acute Rheumatisvi . — A little girl of twenty-two months was going about as usual on 
March 22 ; on being taken up the next morning she seemed in pain and was unable to 
stand, complaining (apparently) of her left ankle, which was supposed to be sprained. 
The next day, however, the right ankle appeared to be similarly affected, and during the 
succeeding two days her knees, elbows, and neck were attacked successively in the same 
way. On the 27th the knee joints, especially the left, were considerably swollen and hot 
with fluid in the joints ; the next day both joints were equally enlarged. The general 
system was only slightly disturbed ; there was no cardiac affection. The knees remained 
swollen for a few days, but gradually recovered, so that at the end of thirteen days she 
could again walk a little. 



Rheu matism 391 

In most attacks the child becomes anaemic. Children, like adults, are 
liable to relapses ; usually fresh joints are affected, with the symptoms 
.attendant on the primary attack. 

The complications and manifestations of rheumatism are many and of 
great importance, as they all centre round peri-endocarditis, and it is the 
danger of these cardiac lesions supervening that makes us look with so much 
care and anxiety at all joint pains in children. As already remarked (see 
p. 336) it is the exception for children to escape suffering from endocarditis 
during an attack of acute rheumatism, and, moreover, peri-endocarditis 
may supervene with but very slight joint pain, or the latter may come on 
later. 

Chorea is another frequent associate of rheumatism, and may either 
precede or follow, or sometimes actually complicate, the rheumatic attack. 
It has been referred to elsewhere. 

Pleurisy and Pleuro -pneumonia occur at times as complications of a 
rheumatic attack, especially when pericarditis is present. 

Erythema multiforme and Urticaria occasionally occur in connection 
with rheumatism and endocarditis. The erythema may take various forms, 
occurring sometimes as irregular patches of redness, at others as red or white 
papules. Erythema nodosum is not uncommon. In all cases where such 
forms of erythema occur, the heart should be carefully examined. Purpura 
occurs also at times in rheumatic attacks. Peculiar nodules, first described 
by Drs. Barlow and Warner, occur in some rheumatic cases, mostly in the 
neighbourhood of joints. They are subcutaneous, the skin being freely mov- 
able over them ; they are most common at the back of the elbows and wrists, 
at the ankles, and by the patellae. In one case seen by us, that of a girl 
suffering from severe chorea and rheumatism, there were several hundreds 
of these nodules, many of them being situated over the bones ; friction 
during the severe movements seemed to act as the exciting cause. They 
were present at the back of the scalp, over the spinous processes, along the 
edges of the scapula, and along the ribs. They are not painful, and vary 
in size from a split pea to an almond. These nodules are, when present, asso- 
ciated with chronic heart disease. 

Diag?iosis. — There is often much difficulty in distinguishing the synovitis 
Avhich accompanies rheumatism from one or other of the many other forms 
of synovitis. Thus there is the acute suppurative arthritis of infants, the 
synovitis of septicaemia and scarlet fever, and the synovitis which is apt 
to go on to effusion and has a chronic course which chiefly attacks the knee-- : 
there are, moreover, the rarer arthritic attacks which accompany haemophilia, 
syphilis, gonorrhoea, and purpura. It may be impossible definitely to say if 
some arthritic attacks are really rheumatic or not ; their subsequent course 
may possibly clear up the doubt. In infants and young children it may be diffi- 
cult to localise the seat of pain in a limb, and consequently a doubt may bo 
raised as to whether in a given case where there is pain ami helplessness the 
joints arc affected or not. Such difficulty may arise in the epiphysitis o\ eon- 
genital syphilis and in the tenderness of the periosteum A\\d occasional 
haemorrhages which are associated with rickets. 

Treatment. — On the least suspicion of any joint affection in a child it 
should be put to bed between the blankets and restricted to a milk diet. It 



39 2 Rheumatism 

is a comparatively small matter if we are over-cautious in our treatment, in 
keeping at rest in bed a child who has but slight joint trouble and who> 
appears to the friends to ail little ; while it is a grave matter to allow a child 
who is suffering from incipient endocarditis to get up and run about, or to 
suffer one to contract endocarditis in consequence of getting up. Knowing 
the readiness with which peri-endocarditis supervenes in mild attacks of 
rheumatism in children, it is our duty to warn the friends of this, and to 
insist on placing the heart under the most favourable circumstances by giving 
it as little work to do as possible. This is best accomplished by keeping: 
the child at rest in bed, perhaps for several weeks after all pain and tender- 
ness have disappeared. 

In the milder cases the only medicine required will be a simple saline 
such as citrate of potash ; the affected joints should be painted with extract 
of belladonna and glycerine, and surrounded with cotton wool. A small 
dose of Dover's powder may be given at night. In the more severe cases 
where many joints are affected and there is much fever, salicylate of soda 
should be given ; five to ten grains may be given every four hours to children 
of from six to eight years of age for two or three days, and then given only 
every six hours or three times a day ; it may be prescribed with a saline or 
given with syrup of orange peel. 

In all acute or subacute cases milk is the best form of food ; it may be 
given in combination with potash, soda, or seltzer water ; as long as there is 
any fever this should be adhered to. There is always a risk of a relapse if beef 
tea, soups, or meat are allowed too early during convalescence. Arrowroot, 
rice, and custards may be allowed when all pain has been absent for several 
days and the temperature has been normal for a week. 



393 



CHAPTER XVIII 

GENERAL DISEASES 

Rickets 

Rickets is a disease that usually makes its appearance during the first two 
or three years of life ; it is characterised by chronic indigestion, deformities 
of the bones, weakness of the muscles and ligaments, and various peculiar 
nervous disorders. Dentition is retarded ; there is frequently enlargement, 
of the liver and spleen. 

The commonest time for rickets to manifest itself is from the first six 
months to the end of the second year, but it is not uncommonly noted during 
the first few months of life, and in rare cases infants may be born exhibiting 
undoubted rickety changes in their bones. During the first year or two of 
life, even in health, the digestive system is worked to its utmost capacity, in 
order that itmay be able to supply the system with sufficient nutrient material,, 
not only for the exigencies of daily life, but also for the rapid building up of 
the tissues which is going on at this time ; an impairment of the digestive 
powers, a weakening of the digestive ferments, or food inadequate in quantity 
or of an improper kind, necessarily means that the tissues fail to receive the 
amount of nutriment they require. This failure of the nutrient powers is an im- 
portant factor in bringing about the changes which characterise rickets. That 
a state of mal-nutrition does not always produce rickets is certain, but it is 
certainly true that it often does, and, moreover, in all cases of rickets of any 
degree of severity there is evidence of a pre-existing failure of the digestive 
powers. In some of the milder forms of rickets, when the ribs are seen to 
be beaded and the bones of the extremities deformed, without any of the 
symptoms which mark the severer grades, the child may be fat and appa- 
rently healthy, and there may be no evidence of a present or past mal- 
nutrition ; but inquiry will generally elicit some past illness or subacute 
dyspepsia, or a history of improper feeding, or some conditions which have 
tended to produce a mal-assimilation or imperfect digestion of the food. 
The deformities produced by rickets may continue to be present long 
after the acute stage has passed away. 

If it be granted, as we think it must be, that a failure on the part o\ the 
alimentary system to supply the rapidly growing body with suitable nutrient 
material is an important factor in producing rickets, there is yet much leu to 
explain, inasmuch as atrophy and tuberculosis and all wasting diseases of 
infants own a similar cause. Why, for instance, should a chronic intestinal 
catarrh lead on to tickets in one ease, tuberculosis in another, gastro- 
intestinal atrophy in another, and final recovery occur in another ? If rickets 



394 General Diseases 

is produced by mal-assimilation, what are the steps in the process, or in 
what elements are the nutrient fluids wanting ? These are questions that 
we think cannot be satisfactorily answered, and all we can attempt to do 
will be to discuss some of the influences which predispose or excite to rickets. 

Hereditary hifiuence. — Is rickets hereditary? Do parents who have 
suffered from rickets in their childhood have rickety children, in the same 
way that phthisical parents have children who readily become tubercular? 
One great difficulty in answering this question is that it is impossible in a 
large majority of cases to be able to satisfy oneself, in the absence of 
.any rickety deformities, whether the parents in any given case suffered from 
Tickets when they were children or not, as they are hardly likely to know 
themselves, and a trustworthy history of their infancy is often not obtainable. 
^Moreover, most infants suffer more or less from dyspepsia or have been ex- 
posed to conditions which may produce rickets : it is not easy to exclude 
such, and to say, dogmatically, that a rickety child must have inherited the 
tendency to this disease. Thus children who have been brought up at the 
breast of a healthy mother, and who are themselves fat and apparently strong, 
will sometimes exhibit beaded ribs and other evidences of rickets during 
their first year, which may be due to the mothers milk being thin and of an 
inferior quality, being deficient in fat and casein. In some cases, however, 
observed by Pfeiffer, who analysed the breast milk in eight such cases, this 
was not so, for in these there was no deviation from the normal amount 
of casein, fat, sugar, and salts ; but there was a deficiency of phosphates in 
the ash. Pfeiffer believes that the tendency to rickets is hereditary and acts 
as a predisposing cause, whilst a deficiency, for some reason or other, of phos- 
phates in the breast milk acts as an exciting cause. 1 While the observations 
are curious and interesting, we believe that in the immense majority of cases 
where nurslings become rickety it is because the mothers milk is poor, or 
it is of improper quality from her having taken little care in the matter of 
Tier own diet, and the infant has suffered more or less from intestinal catarrh 
in consequence. The breast milk of a weakly woman, especially at the 
end of the natural period of lactation, is certain to be poor in fat, while the 
milk sugar is present in abundance, and the nursling maybe fat and yet weak 
and rickety. See case p. 41. 

While we do not believe that it has been satisfactorily shown that a ten- 
dency to rickets is hereditary, in the same sense that a tendency to gout or 
tubercle is hereditary, yet we are far from denying that hereditary influence 
plays some part in predisposing to rickets. We believe that if either father 
■or mother, especially the latter, is weakly from any cause, their children will be 
more likely to suffer from rickets. A woman does much manual labour during 
ner pregnancy, more than her strength will really admit of. or she lives 
under unhealthy conditions : the infant is weakly, is difficult to rear, and be- 
comes rickety : we can hardly doubt that the influence of the mother's health 
has predisposed to rickets, or at least to the digestive troubles which precede 
rickets. We feel certain that weakly or premature infants may become 
rickety, even though the greatest pains and care have been bestowed on their 
feeding and bringing up. The fact that rickets may appear during intra- 
uterine life and the infant be born with beaded ribs and other symptoms of 
1 Jahrb. f. Kindhlk. xxiv. Heft iii. 



Rickets 395 

rickets shows that rickets can be produced apart from any improper feeding, 
and suggests that the influence of the mother's health during pregnancy may 
be an important factor in predisposing to the disease. 

The influence of the mother's health in producing rickets is seen in large 
families, where the later children born are apt to be rickety. It happens also 
at times that first-born children are rickety, especially in those cases where 
the mother is very young. 

Does syphilis in the parents predispose to rickets in the infant ? Parrot 
asserted that rickets was the result of the syphilitic poison — that the latter 
when worn out or weakened produced rickets. Very few, even among his 
own countrymen, have accepted his views. Among the foundlings of Paris, 
and other large cities where syphilis is a common disease, it may be difficult 
or impossible to say exactly what influence syphilis exerts in producing rickets; 
in country districts, where syphilis is uncommon and rickets common, it is 
clearly seen that there is no connection between the two, or only that the 
syphilitic poison has a depressing influence on the system and so predisposes 
to rickets as it appears to do to tuberculosis. 

Dietetic Influeiices. — It has been stated that infants nursed at the breast of 
a healthy mother rarely become rickety, we may say never suffer from severe 
rickets ; while infants who have been artificially fed from the first, and who 
have suffered much from dyspeptic ailments, are nearly always affected. 
Infants who have suffered from diarrhcea, gastric catarrh, bronchitis, pneu- 
monia, and especially those who have had a hard struggle for life, very 
frequently become rickety. Infants who were premature, and who have been 
reared with difficulty, are among those who often suffer. Infants badly fed, 
and those who from ignorance or necessity have been deprived of fresh 
milk and given large quantities of food in which starch has taken the place of 
fat are exceedingly likely to suffer from rickets. That improper feeding plays 
an important part in the production of rickets has been shown in the rear- 
ing of the young lions at the Zoological Gardens, and in the feeding of puppies 
and other animals on lean meat. These animals developed rickets, but im- 
proved at once when given milk and pounded bones. 1 The same thing may 
be seen again and again among our dispensary patients ; a marked im- 
provement in the symptoms following their admission to hospital, where a 
more suitable diet is given than the one which they have been taking. 

Now, while there cannot be a doubt that infants who have been given 
large quantities of sago, sopped bread, arrowroot, condensed milk of a poor 
quality, or one or more of the much advertised patent foods, early develop 
rickets, yet so also do some infants who have been brought up on fresh milk 
and water, milk and cream, and peptonised milk. The food max have been 
theoretically correct as far as quality goes, the child may have been well 
looked after, and the parents or friends are surprised at being told thai it 
has developed more or less of rickets. But children who thus become 
rickety though brought up on fresh or sterilised milk have almost certainly 
suffered a good deal from gastric or intestinal catarrh, and their food has 
failed to be digested and assimilated. It is no uncommon thing to find a 
child of eight or nine months, markedly rickety, being fed with far more milk 
than it can possibly digest, passing curd, pasty stools, and suffering from 
1 See Cheadle, 'Rickets,' Brit. Mod. Vssoc. Meeting, 1888. 



396 General Diseases 

flatulence and colic. A food in which starch or sugar has replaced fat, or which 
in other ways differs from human milk, will be only too likely to give rise to 
rickets ; but the food may have contained fat in normal quantities and been 
otherwise suitable, yet if the child suffers from chronic dyspepsia, and the 
milk food has undergone excessive lactic or butyric fermentation in the 
alimentary canal, and consequently failed to nourish, the child is likely to be 
rickety, and it may suffer laryngismus and convulsions. We must not forget 
that the food itself may have been suitable, but the child may have been 
over-fed and a dyspepsia started which has passed into a chronic stage. 

Hygienic and Climatic Influences. — The children of the well-to-do classes 
suffer less from rickets than those of the poor, and when they are affected it 
is in a milder degree; the same may be said of country children as com- 
pared with the denizens of the slums of our great cities. Rickets is more 
common in damp cold climates than in warmer ones. From these facts we 
gather that bad ventilation, and absence of fresh air and sunlight, are factors 
in producing rickets. That this influence is exercised through the digestive 
organs is very probable. 

From the above remarks it is clear that we believe there are several 
factors in the production of rickets. Hereditary weakness, feebleness of the 
digestive powers, improper food, breathing vitiated air, exposure to cold 
and damp, will together, in some instances perhaps singly, produce rickets. 
Rickets abounds wherever the lower classes of the population are crowded 
together in courts and slums, where the mothers, from necessity or choice, 
are unable to suckle their infants, where fresh cow's milk is dear and of 
poor quality, and infant life is exposed to the various bad influences which, 
poverty and ignorance are certain to produce. Rickets is a rare disease 
where the parents are strong and healthy, the mother able to nurse her 
infants, while taking care of her own health and diet, and where she is able 
to devote her whole time to the care and nurture of her offspring. 

Chemical Theories. — The older authors attributed rickets to the absence, 
or diminished quantities, of lime salts in the food, but very little observation 
was sufficient to disprove this. Others (Seeman) have supposed a deficiency 
of hydrochloric acid in the gastric juice, and that consequently the lime salts, 
instead of entering the blood, passed through the alimentary canal. Some 
have thought there was a deficiency of phosphoric acid or phosphates in the 
food, and that its absence from the blood prevented the formation of bone. 
The ' acid theory ' has also had supporters, who supposed there was an ex- 
cess of lactic acid in the blood, which had been formed from the decomposi- 
tion of milk in the stomach — the presence of the lactic acid dissolving the 
lime salts of the bones and carrying them out of the body in the urine. We 
confess to being completely sceptical concerning all these hypotheses, and 
much doubt if they explain anything as to the pathogenesis of rickets. We 
certainly think that an amount of both fat and phosphates in the food below 
the normal may be one factor in producing rickets. 

Symptoms and Course. — The premonitory or early symptoms of rickets 
may be absent, or so intermingled with those of dyspepsia that it may be im- 
possible to differentiate them. In the slighter grades of rickets the first and 
perhaps the only signs of the affection are slightly beaded ribs and enlarged 
epiphyses at the lower ends of the radius and ulna. In the more severe forms 



Rickets 397 

of the disease the early symptoms are slight fever, the infant being hot and 
restless during sleep ; abundant perspiration, more especially about the fore- 
head and scalp, may then be noticed ; at this time the infant may suffer from 
convulsions and not infrequently laryngismus. His bones may be more or less 
tender, so that he cries on being moved or danced about in the nurse's arms, 
and usually some beading of the ribs can be detected. In the majority of 
cases the abdomen is habitually distended with wind, and there is mostly 
constipation, though, on the other hand, the stools may be loose and curdy. 
The child may be anaemic and the spleen may be felt to be enlarged. 

As time goes on it is noted that there is a delay in the appearance of the 
teeth ; if the first two incisors have been cut, a long interval, perhaps many 
months, elapses before the appearance of the others, and the teeth that have 
been cut are apt to become carious, from a deficiency in their enamel. The 
muscular system is almost certain to suffer, the child cannot sit up from weak- 
ness of the lumbar muscles, and the spine bows out from laxity of the liga- 
ments ; the infant does not use its limbs like a healthy child, making no, 
or poor, attempts at crawling ; its legs are weak, it cannot bear its weight on 
them or even put them to the ground. 

Concurrently with many of these phenomena, marked changes are noted 
in the bony skeleton. The skull early shows these changes, though, if rickets 
does not supervene till the middle or end of the second year, the bones of the 
skull may escape. There is a marked exaggeration of the frontal and parietal 
eminences, with some flattening of the upper surface, so that there is a sort 
of table-land at the vertex, the head assuming a more or less quadrate shape. 
Sometimes there is flattening of the occipital bone behind, so that the back 
of the head looks as if pressed in. In severe cases there are broad shallow 
grooves corresponding with the sagittal and coronal sutures, and consequently 
running at right angles with one another. The fontanelles are widely open 
and may remain so long after they should be closing up, and the edges of the 
bones where they come together to form the sagittal, coronal, and lambdoidal 
sutures are thickened. Instead of, or in combination with, these hypertrophic 
changes at the eminences and edges of the bones, there may be atrophy or 
thinning of the central parts of the occipital or parietal bones, which has 
been termed cranio-tabes. These weak places can be felt by gentle pressure 
exerted with the finger on the occipital or parietal bones, of course avoiding 
the sutures, the bone perhaps bending and bowing in almost like parchment 
beneath the finger. It has been questioned to what extent cranio-tabes is 
the result of rickets, as it is present at times in undoubtedly syphilitic 
children, and also in those suffering from various wasting diseases. We doubt 
whether its connection with syphilis is anything more than a casual one, but 
it is certain cranio-tabes may be detected in weakly infants a few months old 
who exhibit no other signs of rickets, and also in newly born infants. Whether 
it is always to be accepted as pathognomonic of commencing rickets is an 
open question ; but when present in infants over six or eight months o( age 
it is almost always in our experience accompanied by signs o( undoubted 
rickets. 

Characteristic changes take place in the chondral ends of the ribs and in 
the shape of the chest, the latter being most marked in children who suffer 
from bronchitis. The ribs are enlarged or beaded where they join their 



398 



General Diseases 



cartilages : these may be felt or seen at a glance when the chest is exposed. 
The shape of the chest-walls is altered in consequence of the softening of the 
costal ends of the ribs ; the rigidity of the chest walls is impaired at this spot, 
so that there is a falling in of the ribs on each side, while the sternum and 
cartilages are thrust forward (see fig. 65). The sides of the chest, especially 
the region included between the fourth and eighth ribs, bend or curve inwards 
so that a more or less broad vertical groove is formed on each side of the 
chest. The angles of the ribs are often exaggerated or undergo a sharp 
bending or ' kink ' at this spot. With these changes is mostly associated 
a widening of the arch which the ribs make inferiorly, and the abdomen is 
distended and round. If the child be watched, especially if there is any 
bronchial catarrh, the chest walls will be noticed to fall in at the groove on 





Fig. 65. — Tracing of Chest Wall of a Rickety Boy 
of two years of age. 



Fig. 66. — Enlargement of Epiphyses of 
Lower End of Radius and Ulna. 
Child of eighteen months. 



each side, and the tip of the sternum is drawn in during inspiration. All 
degrees of chest deformity may be present, from the extreme degree noted 
above, to a slight prominence or keel-like ridge in front, formed by the ster- 
num, which makes what is called the 'pigeon-breast.' The clavicle often joins 
in the deformity, its normal double curve being exaggerated. The extremities 
show peculiar changes, more especially at the lower epiphyses of the radius 
and ulna, and the tibia ; the shafts are very apt to bend and in the worst cases 
may fracture. The lower ends of the radius and ulna are swollen, the swollen 
portion involving the irregular layer of cartilage, in which calcification is 
proceeding (see fig. 67), which separates the cartilage of the epiphyses from 
the shaft ; in the worst cases this enlargement is very striking (see figs. 66 and 
67). The tibia is usually more or less bent, the curve varying in position and 
degree ; the lower end is, however, most commonly bent inwards (being an 



Rickets 



399 



exaggeration of the natural curve), so that the convexity is outward (see fig. 
76 et seq.\ a deformity which is produced by the child whilst sitting on the 
floor, with its legs crossed under it, and shuffling with its legs so as to change 
its position. The deformity often takes place before the child learns to walk. 
The deformity known as 'knock-knees' is produced later, after the child has 
begun to walk (see fig. 75). The other long bones, the femur (see fig. 70 et 
seq.), radius and ulna, and the humerus, are apt to bend : the bowed 
humerus is sometimes produced by the attendants lifting the child by 
grasping its arms, just below the shoulder. If the child can sit up the spine 
is apt to become bowed, an exaggeration of the natural curve taking place 
in the cervical region, while the dorsal curve is exaggerated and involves 
the lumbar, so that the spine bows out backwards, a result largely due to 
the weakening of the ligaments (see fig. 74). 

It must not be supposed that all the changes 
in the shape of the bones take place in any one 
case, and the degree of deformity differs accord- 
ing to the severity of the case. As before re- 
marked, the shape of the head may be quite 
normal, and only the epiphysial swelling and 
deformity be noted in the ribs and fore-arms. 
Sometimes muscular weakness is the symptom 
which most strikes the friends : the child is 
dyspeptic, has a rounded belly and pale face, 
the teeth are late in appearing ; the child, who 
is perhaps eighteen months or two years old, 
cannot stand or walk, and medical advice is 
sought because the parents think the legs are 
paralysed ; or the child is brought to a doctor, 
as it is supposed he has spinal disease, on ac- 
count of the bowing backwards of the spine ; or 
the pigeon-breast is the most marked and striking- 
symptom which alarms the friends. 

The phenomena noted in connection with 
the nervous system in rickets are among the 
most important. The whole nervous system 
appears to be affected, the nerve centres are in 
an unstable condition and readily discharge 
on the slightest provocation. General convulsions are 
especially during the early stages of the disease ; they vary much in their 
severity, sometimes being slight and passing away quickly, but, on the other 
hand, it is no uncommon thing for a rickety child of a year, eighteen 
months, or two years to die in a few moments in a fit. Laryngismus is 
common, and indeed is almost confined to those who are rickety." Tetany 
is also common in rickety children. A hypertrophic condition oi the brain, 
with a large head, is not uncommon. Rickety children are exceedingly liable 
to bronchial catarrh and broncho-pneumonia, and in them all chest troubles 
are apt to be serious. They arc liable also to suffer from dyspeptic troubles, 
especially diarrhoea. 

In the severest forms of rickets the child is apt to become markedly 




Fig. 67. — Section through Radius- 
of case figured in fig. 66, show- 
ing exaggerated depth and irre- 
gular borders of the proliferation 
and columnar zones of cartilage. 



common, more 



400 General Diseases 

anaemic, and when this is so there is usually enlargement of the spleen. It 
Tias been doubted if splenic enlargement is present in uncomplicated rickets, 
or in those cases only which are combined with syphilis. We certainly have 
seen cases were the spleen was enlarged, where no history of syphilis could 
"be obtained. With enlargement of the spleen there is frequently a marked 
-enlargement of the liver. 

The course of rickets is towards recovery, but progress is frequently very 
slow, especially in those cases where there is chronic derangement of the 
digestive organs. The child is certain to be late in walking ; instead of 'feel- 
ing his feet ' by the end of the first year, he is utterly helpless when his legs are 
put to the ground, and at the end of the second or even the third year, rickety 
children may be seen who are quite unable to bear their own weight on their 
legs. All this time, perhaps, the child is incapable of much exertion and is 
•easily tired. Many dangers attend rickets on account of the weakly state 
of the child. He is especially liable to catch cold ; this may be followed by 
"bronchitis and broncho-pneumonia. The latter is necessarily dangerous on 
account of the weakness of the ribs and feebleness of the respiratory muscles. 

Bronchitis and collapse of lung, or broncho-pneumonia, is exceedingly apt 
to be fatal when it complicates rickets. One of the effects of rickets is to 
stunt the child's growth, as well as to leave him with many deformities, which 
will be discussed in detail later on. The lowering of the child's health pro- 
duced by rickets may last for many years, but in the vast majority of cases 
the symptoms and signs of rickets, if they come under treatment, disappear, 
and the child may grow up into a healthy adult. 

Foetal Rickets.— Congenital Rickets. — In rare cases children are born with 
deformed bones, enlarged epiphyses, and beaded ribs — a condition to which 
the name of rickets can hardly be denied. Other cases have been observed 
in which the bones have been soft and deformed, but which lacked the cha- 
racteristics — both naked-eye and microscopic — of rickets. Hence some con- 
fusion has arisen, and the terms infa7itile osteo-malacia and cretinis77i have 
been applied, as it was thought they resembled these rather than rickets. 
There can hardly be a doubt, however, that children are born rickety, or 
that they become so very shortly after birth. Such cases have been observed 
by Bode, 1 T. Barlow,' 2 and the late Dr. Marshall (of Preston). In Bode's 
case the infant was stillborn, the mother was healthy. The infant's head 
was hydrocephalic, the limbs were short and bent, the chest deformed, and 
the ribs beaded ; the pelvis was narrow. The microscopical examination 
showed changes resembling those found in rickets. In Dr. Barlow's case 
there was a history of the infant being born with deformed limbs, which 
were also tender, and when seen at six weeks old the long bones and ribs 
-were typically rickety, and there was a green -stick fracture of the humerus. 
Dr. Marshall's case was somewhat similar. (See Cretinism.) 

There are several morbid conditions found in children under two years 
of age which are invariably associated with rickets, though there may be 
some doubt as to what relation there is between rickets and these morbid 
states. We refer to the so-called ' scurvy-rickets ' and Anaemia splenica or 
Anaemia pseudo-leukaemia infantum. In the former there is a haemorrhagic 
diathesis usually associated with acute rickets, and in the latter there is pro- 
1 Virchow's Archiv, 93, Heft iii. 2 Clin. Soc. Trans, vol. xxi. 



Rickets 401 

found anaemia with enlarged spleen also associated with rickets. We have 
discussed the latter already, see p. 364. 

Scurvy Rickets, Hemorrhagic Rickets, Infantile Scurvy. — Dr. W. B. 

Cheadle was the first in this country, at least, to recognise this condition, 
which he described as a combination of scurvy and rickets ; and Dr. T. 
Barlow has largely added to our knowledge of the morbid anatomy of this 
peculiar disease by his admirable descriptions of a series of cases with post- 
morterris. 

The first difficulty which meets us in describing this condition is the im- 
possibility of separating clinically cases of acute rickets from cases of ' scurvy.' 
There are 'borderland' cases, as Dr. Barlow would call them, which shade 
away clinically into acute rickets on the one hand, and rickets plus a well- 
marked haemorrhagic diathesis on the other. Thus we may not infrequently 
meet with a child of say eight or nine months of age who has been badly 
fed, and who has well-marked tenderness of the bones, and cries whenever 
he is moved, with also head perspiration and more or less indigestion. 
There may be no external evidence of any haemorrhage to suggest scurvy, 
and yet the child at once improves when its diet is changed in the direction 
of giving it fresh milk, cod liver oil, and orange juice. Perhaps in a similar 
case to the above there is haematuria in slight degree, or the gums are 
haemorrhagic around a tooth that is being cut, the case is now called one of 
scurvy rickets. Now there appears to us to be no doubt that these cases 
are closely associated, and that they cannot be separated. There is the 
strongest probability that in rickets in its early or acute stage or in severe 
cases there is a tendency to haemorrhage, that minute bleedings take place 
from the most vascular parts, such as the periosteum of the long bones, 
especially if there is an injury. In one case coming under our notice, 
that died of an intercurrent disease, we were surprised to find minute 
bleedings had taken place along the epiphysial lines of the long bones and 
ribs. 

In a typical case of scurvy rickets in an early stage where a haemorrhage 
has taken place beneath the periosteum of the tibia in both legs, the most 
characteristic symptom is a loss of power and tenderness of the lower 
limbs. The child cries when it is disturbed, and especially at the approach 
of a stranger. The legs hang down as if completely paralysed, though the 
child can usually draw them up, flexing the knees and hips. The skin is 
tense and shining over the shins and the dorsum of the feet are cedematous. 
In cases such as the above the bleedings are probably small and numerous, 
there is also more or less periostitis as the temperature is often raised a 
degree or two. In several cases we have noted a local thickening o\ the 
femur on recovery. An examination of the mouth will almost certainly show- 
that the gums are haemorrhagic around any teeth that have been out or are 
about to be cut. The napkin may be stained red by blood which is oozing 
from the urinary tract. 

Should the case be more advanced or more severe, there is always 
marked anaemia which strikes the observer at once. There may be e\ idence 
of a considerable haemorrhage beneath the periosteum of the tibiae or femur, 
there may be much swelling and oedema as well as pain and tenderness. 
Bleeding may take place from the periosteum of the hones of the upper limb, 



402 General Diseases 

skull, scapula?, and ribs. A violent fit of crying may have given rise to a 
bleeding beneath the periosteum of the orbital plate, and the eye in conse- 
quence is pressed downwards and the upper eyelid is cedematous. The 
gums are hemorrhagic, and swollen, and spongy, and the breath foetid. 
There may be hematomas beneath the skin and in or between the muscles. 
Purpuric spots and bruise marks, the result of slight injur}-, are often present. 
Hematuria is common see Hematuria, blood in the stools is less common. 
In severe cases it is well to bear in mind the possibility of an internal 
hemorrhage either into the lungs or beneath the dura mater Sutherland . 
In a few cases fractures of the bones have been reported, the common position 
being on the diaphysial side of the growing line. An examination in all 
these cases will show, as far as our experience goes, that there is well-marked 
rickets. Bosses are present on the ribs, the skull is more or less misshapen, 
and perhaps the epiphyses of the long bones are enlarged. 

It is curious how in most cases there is evidence of a periosteal les 
either there is a swelling and the skin is shiny and tense, or there is marked 
tenderness with or without pain on movement. Rickety bone is very 
vascular, and this is especially true of the bone being formed beneath the 
periosteum. In a few cases we have seen anemic rickety children pass 
blood in their urine without any bone tenderness or swelling, and in one 
case a child of fourteen months who was anemic and had been exceedingly 
difficult to feed, passed a considerable quantity of blood in his stools, com- 
mencing when staying away at the seaside in apparent health, though he was 
certainly anemic. He never had spongy gums but he readily bled from 
cracks in his lips. He gradually improved apparently as the result of raw 
meat juice being added to his food. He had lived principally on a malted 
food made with fresh milk, though he had taken scraps of various kinds from 
his parents" table. 

An inquiry into the food which the child has taken will almost certainly 
show that the diet has been faulty, and in a large proportion of the cases the 
child has suffered from vomiting or diarrhoea, or at any rate severe and 
continued dyspepsia. In some cases it was evident that the most extreme 
care had been exercised, or the child would never have survived. The 
common history which has been given in our own cases was that the child 
had been nursed at the breast for awhile and then this for various reasons 
had been given up. Then some form of fresh milk had been tried, but this 
also had been given up in consequence of vomiting or colic. Then some 
patent food or condensed milk had been substituted, and this had been 
continued up to the time of the onset of the symptoms. In ten of our cases 
this substitution had been peptonised milk, either tinned or made fresh from 
cows milk. It has been our experience, and this has also been the experience 
of others, that a continuance for some months of peptonised foods, even 
though made from fresh cows milk, has appeared to give rise to a hemor- 
rhagic diathesis. In three of our cases tinned milk had been used exclu- 
sively for some time before the onset of symptoms. In one of our cases the 
sterilised milk of a well-known dairy company had been used. In seven 
cases fresh milk made with some farinaceous food or malted food had been 
used, the milk having been boiled in preparing the food. In several of cur 
cases raw meat juice, and in one case a raw egg, and in another potatoes were 



Rickets 403 

being given when the symptoms developed. There cannot be any doubt, 
whatever view we may take of the pathology of these cases, that they are 
the result in large measure at any rate of a long continuance of peptonised 
milk, or of some farinaceous or tinned food as an article of diet. That these 
symptoms may also be produced by fresh boiled milk is, we think, also 
certain, and in occasional cases when raw beef juice, raw eggs, and potatoes 
form part of the diet. The fact that we have met with cases of ' scurvy- 
rickets ' affecting children who have taken fair quantities of fresh boiled milk 
and in some cases raw meat and even potatoes, has made us have some 
misgivings as to whether these cases were instances of classical scurvy. We 
entertain no doubt, however, that a hemorrhagic diathesis is set up by a 
long exclusive use of peptonised foods or dried malted milk. 

Morbid Anatomy. — The most striking appearances in connection with 
rickets consist in the changes in the bones. In the first place, chemical 
analysis shows there is a deficiency of lime salts in their constitution, and 
an excess of organic matters. Normally they contain, roughly, 65 per cent, 
of inorganic constituents and 35 per cent, of animal matters ; in rickets, all 
degrees of decrease of inorganic matters may take place, but in a severe and 
well-marked case the proportions are reversed, so that there is only about 
35 per cent, of mineral basis and 65 per cent, of gelatinous or organic 
matters (A. Baginsky). That there is a deficiency in calcium salts is evident 
from the spongy nature of the bone, its softness, and the readiness with which 
it ' bends ; ' while the spaces between the bony trabecular are seen to be filled 
with juicy material. If a rib taken from a well-marked case of rickets during 
the acute stage be examined, it will be found not only to be wanting in 
rigidity, but it can be bent about like a thin lath, and, if doubled up, fractures or 
'gives' with the greatest ease ; the fracture may be only partial, or perhaps the 
ends of the bones are only held together by the fibrous and muscular tissues 
attached to them. In the same way the fore-arm of the cadaver may perhaps 
be bent by taking it in the two hands and applying moderate force, or it may 
* kink,' and on dissection both radius and ulna will be found to be fractured. 
Other long bones may behave in a similar way if sufficient force is applied. 
The ribs, where they join the cartilages, will be noted to be much swollen ; 
fractures, recent and old, may be present at the angles of the ribs and the 
lower ends of the radius and ulna where they join the epiphyses. A section can 
readily be made with a strong knife through the enlarged end of the rib, and if 
made in a direction from before backwards it will be seen in most cases that 
the pleural side is more prominent than the external side of the swelling, and, 
moreover, the enlargement is produced by the expansion of that portion of 
cartilage— the proliferation and columnar zones— in which certain changes 
are going on preparatory to the deposition ot lime salts in the matrix of the 
cartilage. If a comparison be made with the end of a healthy child's rib, 
it will be seen in the latter that between the cartilage o\ the rib, which is 
yellowish and opaque, and the cancellous tissue of the rib, there is a line of 
translucent and bluish cartilage, about |J inch in breadth at birth, and ab 
.', inch at a year or eighteen months old (Kassowitz) : this line is perfectly 
regular and straight ; the breadth of it depends upon the rapidity with which 
growth is going on, which is greater during the later months ol foetal life 
and those immediately succeeding birth than it is Liter. In rickets the 



404 



General Disc.:::; 



activity of these preparatory changes in cartilage is enormously increased, so 
that the multiplication of cartilage cells takes place with gTeat rapidity, and 
with this there is a softening of the cartilage and matrix, and a consequent 
increase in size of the proliferation and columnar zones, so that the trans- 
lucent line seen in normally growing bone is increased in breadth to 
perhaps ^ inch or more, and there is a bulging or swelling in this posi- 
tion which is visible through the skin of the chest walls and corresponds to 

the junction of the ends of the 
ribs with their cartilages (see 
fig. 6S . Not only does this 
normal line become a broad 
band of jellylike material in- 
terposed between the cartilage 
and bone, but the boundary 
between it and the cancellous 
tissue is very irregular and ill- 
defined, inasmuch as an irregular 
calcification of the matrix is going 
on. and trabecular of calcified 
material with wide medullary 
spaces are being formed instead 
of true cancellous tissue. A 
spongy structure is built up which 
is wanting in strength and ri- 
gidity*. Similar changes are 
going on beneath the periosteum : 
there is a calcification of the 
inner layer, and spongy- bone is 
built up instead of the firm, 
hard, compact tissue which forms 
the outer shell of healthy bone 
see fig. 69 . It is clear that, if 
yS.* the compact hard bone which 

—Longitudinal section through the junction of a forms the shaft of the bone IS 

dits :; irtilage,finoi : r.::z:;- Child of tw-ovears. replaced by trabecular or arches 

B, proliferation zone, deeper than normal : C. columnar of brittle, badly formed bone, 

zone, depth and breadth much increased ; mtf depo- th b \ vl] rea( - il v bend and 

sitionof lime salts m the cartilage— 'metaplastic ossifi- , J 

cation : Sp, spongy tissue, with wide spaces filled with snap, and be simply held tO- 

soft grumous material, containing manv cells : :.:.:. _ -t Q _ • -1 /•.„„, _ __•,__*_--„, 

; ; ;: "..vessel. ' gether by the nbrous periosteum 

and perhaps some of the fibroid 
material which forms in the substance of the bone itself. The bones may 
remain soft and brittle for many months, but finally they harden, perhaps in 
a faulty position, and a sort of sclerosis or eburnation of bone takes place, 
so that the compact tissue of the bone is abnormally hard. Should a fracture 
take place there is a large amount of callus formed at the seat of fracture. 
In acute cases, or in those in which the harmorrhagic diathesis is present, 
bleedings large or small may be found beneath the periosteum and along 
the line of junction between the epiphysis and the shaft. 

The bones of the skull are abnormally soft and can be readily cut with a 




Ri; 



Rickets 



405 



knife, and are much more readily bent or doubled up than are healthy bones. 
Their edges are thickened and spongy on section, much juicy-looking fluid 
•exuding ; the ossifying centres are usually thickened, so that the frontal and 
parietal eminences are exaggerated. In some cases prominences or bosses 
may be present on the parietal or frontal bones, near the sutures ; but it has 
been denied that these are really rickety changes, though they certainly do 
occur in rickety subjects. Instead of, or in association with, the hypertrophic 
changes just referred to, certain atrophic changes take place, the bone 
becoming thin, almost transparent, in places ; this thinning of the bone is 
chiefly present in the parietal and occipital bones. If the dura mater be 
stripped off and the bone held up to the light, it will be seen to be thin in 
places, perhaps almost as thin as parchment ; at these spots it readily yields 
to the pressure of the finger, bending in under the slightest force. Rickety 
skulls are usually large ones, not 
only that they look large in conse- 
quence of the thickness of the pro- 
minences on the parietal and frontal 
bones, but their capacity is increased, 
the brain being larger than usual ; it 
is possibly the pressure of the brain 
within that causes the atrophic 
•changes in the bone. 

The changes found in the internal 
•organs are not usually very marked 
unless death has taken place, as it 
not infrequently does, from broncho- 
pneumonia : then varying degrees of 
bronchitis, pneumonia, and collapse 
of lung are present. The brain is 
frequently found of large size, the 
•convolutions well-marked, the sub- 
stance fairly firm ; such brains are 
said to contain an excess of the 
neuroglia elements. The liver and 
spleen are usually enlarged and firm, 
and the former on section has a 
•'gummy' or more or less translucent 
appearance. Concerning the blood 
but few observations have been made. 
Dr. Goodhart has observed in some 
of his cases a deficiency of corpuscles, 

in some deficiency of colouring matters, in some the blood crowded with a 
granular detritus, and in others the corpuscles were of four or rive different sizes. 

The most recent examinations of the blood in rickets have been made by 
Felsenthal, who examined the blood in twelve cases oi rickets, varying in age 
from six months to two years. He found the number o\ red blood corpuscles 
nearly normal, but the haemoglobin diminished v _|o to 50 per cent — Fleischel), 
the number of white corpuscles was increased two to five times. In s< 
cases some of the red corpuscles were nucleated. 




Fig. 69.— Transverse section through the Shaft 
of the Ulna from a Rickety Child of thirteen 
months, x 10. (Kassowitz.) Showing spongy 

tissue beneath the periosteum instead of the 
compact tissue of normal bone. 



406 General Diseases 

Treatment. — If rickets is due to the mal-assimilation of the products of 
digestion or to faulty digestive processes, we can hardly hope to discover 
any specific for its cure, but must direct all our efforts to secure that suit- 
able nourishment in appropriate quantities is taken, and that the digestive 
apparatus shall be in good working order. Directly the first symptoms 
make their appearance, whether they are tenderness of the bones, sweating 
about the head, or enlarged epiphyses, spongy gums, haematuria, we should 
carefully inquire into the diet, as it is probable that the child is either not 
digesting its food properly, or it is not being properly fed. The condition of 
the digestive organs and the state of the blood act and react on each other, 
the intestinal juices are weak because the blood from which they derive the 
materials to form their secretions is weak and poor in quality, and the blood 
remains of poor quality because the digestive juices are feeble and unable to 
convert albumen into peptones, and supply the first step towards converting 
the food taken into blood. The child suffering from rickets in the acute 
stages requires albuminous and fatty foods in the most easily digested forms, 
such as cream, whey, raw meat juice, while all forms of peptonised or tinned 
foods should be interdicted. Probably it will be found that a child so 
affected is suffering from dyspepsia, the abdomen is large and distended 
with gases given off during intestinal digestion, while large masses of un- 
digested curd are being passed. The treatment must be commenced by 
cutting down the supply of curd of milk, by diluting it largely with whey 
or barley water. In the worst cases milk may have to be withdrawn entirely 
for a Avhile, and raw or semi-cooked meat juice, with barley water, substituted. 
In older children pounded raw meat may be given. Dextrin and maltose 
in any form are preferable to sugar in excess or starches. Cream in small 
quantity will often agree, though fat in the form of cod liver oil is often more 
readily digested than any other form. A well-made emulsion may be given 
at any time, beginning, if there is much digestive disturbance, with a few 
drops only; care being taken not to give an excessive quantity. Orange, 
lemon, grape juice or apple juice should be given in all cases where there is 
a tendency to haemorrhage. Potato pulp is useful in the same condition. 

The importance of fresh air, especially sea air, in the treatment of rickets r 
cannot be over-estimated, and when the disease first declares itself a change 
to the seaside or into the country if the weather is warm enough is likely to 
be attended with the greatest benefit. In urging the friends to send the 
child out into the open air the tendency which rickety children have to 
bronchitis must not be forgotten, and the importance of warm woollen 
garments must be insisted on ; especially is this important where there is 
much sweating. If the weather is cool, the child's feet should be carefully 
wrapped up while he is out in his carriage ; a bottle of hot water at his 
feet will often prevent a chill. 

The most careful handling must be practised in acute cases, as the 
bones easily fracture or a haemorrhage may take place. The prone posi- 
tion on soft cushions in a cot or carriage is better than much nursing in 
the arms, as the limbs are easily bent and the spine bows out if the child is 
allowed to sit up much. 

Of medicines, the most important are those which assist digestion or 
correct the faulty condition of the mucous membrane of the stomach and 



Rickety Deformities 407 

bowels, and those which aid nutrition and improve the character of the blood. 
Vomiting, constipation, dyspepsia, and diarrhoea must be treated by appro- 
Driate medicines : small doses of mercury and chalk, rhubarb and soda, 
pepsine or bismuth ; care should always be taken to overcome the constipa- 
tion so often present. Of tonics, cod-liver oil emulsion, or cod liver oil in 
combination with malt extract, is by far the most important, though in 
practice it is common to find it is being given in excessive quantities and at 
a time when the digestion is enfeebled. In such cases it may be given by 
inunction. Phosphate of soda with tartrate of iron and glycerine is a useful 
tonic, assisting the action of the bowels and combating the anaemia so often 
present. Iodide of iron is also useful. 

Small doses of phosphorus have been given by Kassowitz, Wegner, and 
A. Jacobi, who claim for it an almost specific action. Other physicians have 
been disappointed with the results obtained by its administration. It may 
be given in doses of 5 foj- to T fo gr. in cod liver oil, two or three times a day. 

Rickety Deformities. — Distortions of the lower limbs as a result of 
rickets form a large and important group of the deformities of childhood. 
Most commonly all the long bones of the limb are affected, and there may or 
may not be distortion of the articular surfaces at the knee. In many instances 
the deformity is limited, or at least most marked either in the shaft of the 
femur, the lower third of the tibia, or the lower end of the femur. 

Curvature of the shaft of the femur takes place either with its convexity 
forwards or in severe cases forwards and outwards. There is then a wide 
space between the thighs, and the quadriceps stands out very prominently 
over the convexity of the bone ; the patient is short and stunted-looking, the 
gait waddling, and there is knock-knee or bow-leg to a greater or less degree. 

The whole of the shaft takes part in the curve, as is seen in fig. 70. In 
this child the deformity was extreme, and was accompanied by so much 
rotation of the lower end of the femur upon a vertical axis that the leg and 
foot faced directly outwards instead of forwards. In this case osteotomy 
was performed at the most convex part, and the limb turned round as well 
as straightened, so that ultimately the feet were natural in position (fig. 72). 
Sometimes the curve is limited to the lower end of the diaphysis. 

Rickety deformities of the upper limb are seldom of such extent as to 
interfere with the perfect use of the arms or to require operative treatment. 
Obviously this is because no such strain is put upon the arms as upon the legs 
in childhood. It is rare for even the application of splints to be necessary, 
and we have hardly ever had occasion to straighten forcibly, never to osteo- 
tomise, a rickety deformity of the arms. The distortions are most commonly 
produced by the child crawling upon the hands, and consist chiefly in bend- 
ings of the shafts of the bones. We have, howe\ er, seen a condition analogous 
to genu valgum, but reversed i.e. instead of the normal outward obliquity 
of the fore-arm in extension, it was directed inwards so that the convexity 
of the bend was outwards at the elbow ; this disappeared during flexion 
as mgenu valgum^nd was probably due to a similar bony condition, though 
we could not satisfy ourselves o( the exact seal o( deformity. A similar 
condition may occur as a result oi~ separation of the lower epiphysis oi the 
humerus and irregular union. In the humerus the deformity consists usually 
in curvature with the convexity outwards, 





Fig._7r.— Shows the attitude habitually assumed La- 
this child, which resulted in the deformity shown in 
hg. 70. 



Fig. 70. — Rickety Deformity of the Femcra, 
caused by the altitude shown in the next 

f.srure. 





Fig. 72. — The same child shown in the 
last two figures. The limbs have been 
straightened by osteotomy. 



Fig. 73. — A child aged 7 years, showing extreme stunt- 
ing from premature Synostosis, as well as various 
deformities, all the result of Rickets. The child 
could not stand alone. 



Rickety Deformities 



409 



The rickety deformities chiefly amenable to surgical treatment are those 
of the spine and limbs ; distortions of the chest and pelvis can only be 
improved by general management of the health, and prevented from getting 
worse, though it is possible that gymnastics, directed especially to exercise 
the inspiratory muscles other than the diaphragm, and to increase the 
inspiratory capacity, may somewhat improve rickety chests. For the pelvis, 
even if the distortion is noticed before adult life, nothing can be done except 
to prevent the deformity from being increased. 1 

The rickety spine is met with in two forms : in one there is a general 
curve convex backwards, kyphosis (fig. 74), affecting the whole dorso-lumbar 
region ; in the other there is lordosis (fig. J3). 

The first form is that met with in infants and young children before they 
begin to walk ; the other variety is usually secondary to deformities of the 
lower limbs, and is therefore most frequently 
met with after the age of two years. Lateral 
curvature is considered later. 

The kyphotic rickety spine is readily 
distinguished from other spinal curvatures 
by the age of the child, the evidence of 
rickets elsewhere, the extent of the curve, 
which is large and rounded, never acute 
or angular, and the flexibility of the spine, 
so that by laying the child flat or hold- 
ing it horizontally by its arms and thighs, 
face downwards, the curve speedily dis- 
appears. Care must, of course, be taken 
in applying this test. Finally, there is no 
pain, except in some cases the general 
rickety tenderness, and no evidence of 
caries in the shape of abscess, paralysis, &c. 
The attitude of a child suffering from rickety 
spine is well seen in fig. 74 as compared with 
that in caries (figs. 136 and 137). 

All that is required in this condition 
is the general treatment of the rickets and 
recumbency, not implying by this that the 
child is to be kept in bed in a stuffy room, 
but that it is not to be kept sitting up on 
its nurse's lap, except for very short periods at a time. These means should 
be continued until the health is improved, and the spinal muscles strength- 
ened by friction and salt-water bathing. A sheet ot gutta-percha or other 
material may be bandaged to the spine to keep it straight, if preferred, in 
the intervals of friction (Noble Smith). Unless neglected, the spine always 
recovers, and regains or rather develops its natural curves. 

1 Chance, quoted by Noble Smith, found pelvic deformity in only 1c 1 cases out of 
600 rickety patients, while Reeves found it in 210 cases out of 1,000. Lane believes 
tin- deformities of the lower limbs area 11 secondary to alteration in the shape of the sacrum. 
His paper in the La met, August o, 1800. should be read by those interested in the mode 
of production of deformities. 




Fig. 74.— Rickety Curvature of the Spine. 
The Anteroposterior form. 



4 io 



General Diseases 



The lordosis of rickets may be mistaken for a secondary deformity due to 
hip disease, congenital dislocation of the hips, &c, but the absence of these 
conditions is readily made out, and other rickety deformities will be found 
present. Its appearance is seen in fig. 73, which may be compared with that 
of a case of congenital dislocation (fig. 157). 

It should be remembered that lordosis always results from some cause 
tending to throw the upper part of the spine forward in standing, such as 
caries of the upper part of the column, stiffness of the hip joints, distortion 
of the legs, or undue weight in the upper part of the body or head ; in very 
rare instances lordosis may result from caries of the spine directly, chiefly 
when the arches are the seat of disease : it is then due either to actual de- 
struction of the arches or to muscular spasm. Lordosis combined with a 
lateral curve may result from unilateral deformity of the lower limb in 

infantile paralysis, loss or shortening 
of one leg, &c. ; all these possibilities 
should therefore be kept in mind before 
it is concluded that the condition is 
simply rickety. 

As the lordosis is usually secondary, 
as already stated, to deformities of the 
legs, its treatment must be secondary 
to that of the limbs, and no special 
applications or apparatus are required. 
Where it is compensatory to angular 
curvature, it is, of course, necessary, 
and does not admit of treatment. 

Knock-knees.— Deformity of the 
lower end of the femur, resulting in 
knock- knee ox genu valgum, occurs in 
several different ways besides the one 
already described. The inner part of 
the shaft at the epiphysial line some- 
times grows more rapidly than the 
outer (Mickulicz) ; hence the inner 
half of the shaft is longer than the outer, the inner condyle descends lower, 
the line of the knee-joint becomes oblique, and the tibia is set at an obtuse 
angle with the femur. This condition may be due to premature synostosis 
at the outer half of the growing line (Oilier and Tripier), a condition found 
so often in rickets, and explaining largely the stunted form of extreme cases. 
Vide figs. 73 and 78. Sometimes the same results follow from absolute 
overgrowth of the inner half of the epiphysis and the internal condyle as 
compared with the outer. In other instances, dependent upon the irregular 
ossification characteristic of rickets, the outer condyle does not develop, and, 
though the inner half of the epiphysis is not absolutely larger than in healthy 
it is so relatively to the aborted external part. Again, the soft, ill-developed, 
rickety bone, though symmetrical at one time, actually wastes or is absorbed 
as the result of pressure, and a corresponding deformity results. No doubt 
in some of these children a yielding of soft, ill-formed ligaments is the pri- 
mary condition, and the bone changes only occur as the result of the slight 




\# 



Fig. 75. — An ordinary case of Knock-knee. 



Rickety Deformities 4 1 i 

obliquity produced by this yielding. The deformity is, however, sometimes 
congenital. 

In explaining the cause of the particular kind of deformity it must be 
remembered, first, that the femur is normally set at an angle with the tibia. 
and not vertically upon it ; secondly, that these children often assume attitudes 
in which the weight of the body and limbs so presses upon certain parts of 
the shafts of the bones that they yield, and curves result. Such deformities are 
produced by habitually sitting cross-legged, as is seen in fig. 71, &c. Other 
reasons are that in certain cases congenital inequality in length of the limbs 
throws the weight of the body both unequally and obliquely upon one leg ; l 
and again, where the deformity has arisen before the age at which walking 
begins, the pressure of the nurse's arms and the leverage of the weight of the. 
limbs themselves acting over the nurse's arms may produce deviation. Con- 
genital or acquired valgus, slight degrees of infantile paralysis, or any cause 
tending to throw the weight out of the normal line, will in some instances 
prove the starting point. In all cases it is clear that, as the bones are soft 
and unduly yielding, a pressure that would have no effect upon a healthy 
bone will cause deviation in a rickety child, and that, when once the curve is 
started, it will always tend to increase more rapidly. 

It is not improbable that the irregular ossification of rickets prevents the 
normal architecture of the bone from being built up and so weakens it— i.e. 
the special arrangement of arches and struts in the cancellous tissue is not 
preserved. 

Sometimes knock-knee is due to distortion of the tibia rather than the 
femur, and it will usually be found that the upper tibial articular surfaces 
are misshapen and bevelled off. This is, however, generally a secondary 
condition. 2 

Bow-leg-, genu varum or genu exlrorsum, is a deformity which, though, 
dependent upon the same general causes as knock-knee, differs from it in 
most instances in its mechanical causes ; thus it is rarely dependent upon 
a local inequality of growth in the lower end of the femur, but is usually a 
general as opposed to a local curve of both femur and tibia, and is not limited 
to the region of the knee. It is most commonly found in one leg, the other 
being the subject of knock-knee, and in such cases it will nearly always be 
found that the knock-knee has appeared first and the bow-leg later ; in fact,, 
the bow-leg is the result of the knock-knee. If such a patient is stripped, 
it will be found that the axis of the trunk is directed from one shoulder 
obliquely downwards to the hip of the knock-kneed limb : then the line oi 
pressure, following the axis of the thigh of that side if produced, would pass 
through the region of the opposite knee : hence yielding to this pressure 
produces an outward bowing of the whole of the opposite limb. It is true 
that the curve of bow-leg is not quite even, and is usually sharpest at the 
weakest part of the leg— the lower third of the tibia ; much more rarely 
there is a true genu varum y or bowing out, mainly at the knee itself; in such 
cases the head of the fibula is usually very prominent. 

Double genu valgum occurs when the changes in both legs begin at the 
same time and go on at the same rate ; double bow-leg results either from 

1 Reeves has laid stress strongly upon this feet. 

- Noblr Smith believes it to be .1 main cause of knock k 



412 General Diseases 

local changes exactly opposite to those of knock-knee, or, more often, is started 
by the position assumed in sitting by the child, and increased by the weight 
-of the body subsequently. Thus it is common to see children sitting on the 
floor with both thighs somewhat abducted and rotated outwards ; in this 
position the limbs rest on the hips and ankles, and the knees are quite 
-unsupported. The weight of the limbs then tends to bend them outwards, 
.and produces bow-leg, while, if the feet are crossed one over the other, the 
curve will be most marked at the lower third of the tibia, and the leg which 
Tests upon the other will have more of an anterior, and less of an external, 
•curve than its fellow (fig. 76). 

Deformities of the tibia are more complex and difficult to explain than 
those of the femur ; besides the general outward curve already described 
as a part of bow-leg, there are found curvatures of the tibia alone, the 
femur remaining quite or nearly straight. The most common curve in the 
tibia is a sharp bend with its convexity outwards and forwards at the lower 
third. 



/!'' 




u 








Fig. 76. — Shows how sitting ' cross-legged ' Fig. 77. — An ordinary case 

produces Curvature of the Tibiae. The of Bow-leg. 

right foot is resting on the ground. 

Sometimes there is a projection outwards and backwards of the upper 
part of the shaft, just below the tuberosities, giving almost the appearance of 
a subluxation backwards at the knee joint. There is sometimes a condition 
of hyperextension in these patients, but the appearance is, we think, often due 
to the distortion mentioned (fig. 73). 

In some cases there is a bend forward and inwards at the middle of the 
shaft, or rather, as this is associated with genu valgum, it is to be described 
as a bending outwards and backwards of the lower half of the leg upon the 
upper. 

It is common in severe cases of genu valgum to find a well-marked rotation 
of the tibia upon its vertical axis, just as already described in the femur, so that, 
instead of looking inwards and forwards, the inner or subcutaneous surface of 
the tibia looks almost directly forwards (or sometimes the rotation is inwards 
— Reeves) ; the upper third of the tibia may look almost directly forwards, 
the lower third inwards and backwards. In such cases the inner border of 



Rickety Deformities 4 l 3 

the tibia is very strongly marked, forming a prominent ridge somewhat, 
spirally twisted, ending below at the convexity of the forward curve, and above 
at the inner side of the internal tuberosity (fig. 78). In many cases, especially 
in those of long standing, whether this inner border is well marked or not, 
there is a prominent spur-like buttress of bone developed below the inner tube- 
rosity at the insertion of the internal lateral ligament ; this spur, the exist- 
ence of which was, we believe, first pointed out by Mr. Clement Lucas, is- 
probably the result of ossification of the liga- 
ment as a result of strain and irritation, 
somewhat as in the case of ' rider's bone ' and 
other instances of bony overgrowth at the 
attachment of greatly used muscles. The 
prominent ridges, as stated by Mr. Noble 
Smith, are most marked when the disease is 
arrested and the stage of hyperostosis has 
come on. Sometimes there is a flat surface 
of bone running up from the spur to the inner 
condyle of the femur (Macewen) ; in severe 
cases this is very striking, and the spur 
reaches down far below the direct insertion 
of the ligament. Two other conditions asso- 
ciated with these deformities require notice : 
one is that the patella in severe cases of 
knock-knee tends to ride outwards upon the 
external condyle, and even to be dislocated 
quite to its outer surface during flexion of the 
limb. This is the result partly of deficient 
size of the external condyle and partly of the 
bony curves, so that the quadriceps, acting 
in a straight line, does not make, traction in 
the axis of the bones. The patella may also 
sink so deeply into the intercondylar notch 
in flexion that its position may be marked by 
a depression. The other condition referred 
to is the direction and arch of the foot. In 
knock-knee the foot would naturally point 
outwards in consequence of the alteration in 
the axis of the limb, while in bow-leg the toes 
point usually, though not always, forwards or 
slightly inwards. Besides this, there is in 
some instances flat-foot more or less severe. 
It has been asserted that flat-foot is really the cause of genu val& 
but that this is not so in by any means most eases is readily shown. 
Very often, instead of flat-foot, there is a condition oi pes cavus, together 
with a peculiar spasmodic contraction of the great toe. Both the cavus 
and the spasm of the flexor of" the great toe are evidentl\ due to the 
efforts made to obtain a firm grip of the ground in order that the instability 
caused by the knock-knee ma)' be counteracted. Sometimes the great-toe 
spasm exists when flat-foot is present, and it is seen in bow-leg and curve of 




Fig. 78. — A case of severe Rickets, 
showing most of the commoner de- 
formities, as well as dwarfing from 
Synostosis. 



414 General Diseases 

the tibia alone as well as in knock-knee. The foot is inverted to prevent 
strain upon the internal lateral ligament of the ankle, the flexors of the toes, 
and tibialis posticus, as well as to allow the foot to be placed flat upon 
the ground ; this tends to bring the bearing point upon the outer side of the 
foot and to remove the ball of the great toe from the ground ; then, to com- 
pensate for this, the toe is flexed so that the last phalanx may take a share 
in the support of the body. These points are to some extent shown in the 
preceding figures. 1 

To summarise, then, the following deformities may exist in the lower 
limbs as a result of rickets : 

1. Curvature of the shaft of the femur, with its convexity forwards, or 
forwards and outwards throughout its whole length, together with rotation of 
the lower half upon the upper through a vertical axis. 

2. Diaphysial overgrowth on one side of the growing line, absolute, or 
relative from synostosis of the other half. 

3. Overgrowth of either condyle, with absolute or relative smallness of the 
other condyle. 

4. Curvature of the lower third of the femur, with its convexity inwards 
(according to Macewen the commonest cause of genu valgum). 

5. Curvature of the shaft of the tibia as a whole, the convexity being 
directed outwards. 

6. Curvature of the upper part of the tibia, so that the convexity is 
•directed backwards and outwards : possibly this distortion is sometimes at 
the epiphysial line. 

7. Curvature of the shaft of the tibia at the middle, the convexity being 
directed forwards, or forwards and inwards. 

8. Curvature of the shaft of the tibia at its lower third, the convexity 
looking forwards and outwards, more rarely directly forwards. 

9. Rotation of the tibia spirally upon a vertical axis. 

10. Overgrowth of the ridges on the tibia, especially the internal border 
and the region below the inner tuberosity ; similar outgrowths sometimes occur 
about the internal condyle and along the concavities of the curves of the femur, 
as well as in the neighbourhood of any of the epiphysial lines. 

11. Dislocation of the patella outwards. 

1 2. Flat-foot, pes cavus, spasmodic contraction of the flexor longus pollicis. 

13. The muscles and ligaments on the concavity of the curves in either 
direction may be contracted and shortened, those on the convexity stretched 
and weakened. 

14. The pelvis and lower limbs may be stunted as a whole from lack of 
development or premature synostosis. 

Late Rickets. — Though perhaps hardly coming into the category of 
children's diseases, mention must be made of the so-called ' late rickets,' or 
* rickets of adolescence,' in which deformities, knock-knee, flat-foot, and 
more rarely bow-leg, come on between the ages of twelve and twenty years 
or thereabouts, the deformity being a bony and not merely a muscular or 
ligamentous one in the case of knock-knee. 

This condition has been attributed to a disease allied to osteomalacia ; 

1 Macewen believes that flat-foot occurs in children before walking, but that on walking 
the cavus and toa spasm are developed. 






Rickety Deformities 415 

it has also been described as relapsed rickets, and by Mr. Lucas has been 
said to be associated with masturbation and albuminuria. As to these alleged 
causes we may say that it is not often, we think, relapsed rickets, for we have 
seen many instances where there was no evidence that rickets had ever 
existed in childhood. It is not osteomalacia, for the patients never die of the 
disease, the process becomes arrested, and it does not occur under the con- 
ditions met with, nor attack the parts affected in osteomalacia. It is certainly 
not due to, nor even associated with, either albuminuria or masturbation in 
by any means all instances. We have examined such patients a good many 
times, and in only one was there even a trace of albumen in the urine, and, 
as is well known, this may occur quite apart from the condition under dis- 
cussion ; in none of our cases was there any evidence of masturbation. It 
is, we believe, due simply to weak health, bad air, long standing, poor food — 
in short, to bad hygienic conditions at a time when growth is active in the 
limbs — in fact, mainly to those causes which produce rickets in earlier life, 
but in consequence of the greater strength of the skeleton and its more com- 
plete ossification, as a rule it only produces deformity in those parts on which 
the greatest strain is thrown ; in some cases there is well-marked enlarge- 
ment of the epiphyses, of recent appearance, and not dating back to the 
usual time of rickets : this we have seen, and other cases have been recorded 
where both the external and microscopical appearances were identical with 
rickets. 1 The affection is, we think, best described as late rickets ; it 
furnishes a large number of the patients upon whom osteotomy in adult life 
is performed. 2 

Summary. — A child, then, suffering from knock-knee the result of rickets, 
will present the following appearances in addition to evidences of rickets in 
other parts. As he stands the femora will be seen to project markedly for- 
wards and outwards, the extensors of the thigh being firm and prominent. 
There is often some flexion of the thighs upon the pelvis, and of the legs upon 
the thighs ; and secondary lordosis, resulting in a peculiar doubled-up and 
crouching attitude. The legs are set at an obtuse angle with the thighs, the 
patellae are displaced outwards, and the internal condyles of the femora look 
forwards and inwards, instead of directly inwards ; the whole limb is in fact 
rotated outwards. The tibial ridges are unduly developed, and there is a 
spiral twist in the leg. The feet are directed outwards, though the toes are 
somewhat adducted, and spasmodically grasp the floor, the flexors being 
strongly contracted, especially that of the great toe ; the arch of the foot is 
exaggerated, or may, on the other hand, be lost. In walking, one knee passes 
in front of the other, in severe cases to such an extent that the appearance is 
that of a person walking cross-legged. The patient's height is much less 
than it should be from the actual length of the limbs, and he is easily tired 
and complains of aching of the legs, especially on the inner side ot the 
knee if the deformity is increasing. In other instances, however, though 
much deformed, the child is as active and Sturdy as his fellows, and makes 
no complaint of pain 01 tiredness ; when this is so, the distortion is usually 

1 Vide Clutton, St. Thomas's Hospital Reports, 1884, and Mickulica referred to in 
Macewen's book. 

- Mr. Reeves in Practical Orthopaedics gives an elaborate account /.ion of 

these deformities, which we are not altogether able to follow. 



416 General Diseases 

not increasing. On examining the knees more closely it is found that 
on flexion of the joint the leg can be brought into the same line with 
the thigh — a result due to the slipping back of the tibia from the more promi- 
nent part of the condyles to the posterior surface. 1 The internal condyle 
can be felt to be larger and to descend lower than the external, so that if 
the limb is placed in such position that the lower borders of the two condyles 
are on the same level, the axis of the femur is much more oblique than in 
a healthy limb (Reeves). The patella in extension keeps its natural position ; 
while in flexion, as already noticed, it slips outwards and leaves the inter- 
condylar notch plainly perceptible, 2 the appearance being much that of fig. 176. 
On attempting to straighten the limb during extension this will be found 
impossible, though a little lateral movement may take place, and the tendons 
of the biceps and the ilio-tibial band of fascia will become very tense. The 
head of the fibula is sunken, and concealed deep within the angle between 
the tibia and femur. The seat of pain and the tubercle at the insertion of 
the internal lateral ligament have been already alluded to. 

The degree of deformity present varies greatly, but never reaches nearly 
the extent in children that it does in adults ; in an adult case we have seen 
the leg almost at a right angle with the thigh, and in another that we 
operated upon there was 19^ inches between the malleoli when the inner 
condyles were in contact. In double genu valgum ten inches deviation 
would be an extreme case in a child, and five inches a severe one. 

In measuring the deformity it is best to lay the child upon a flat, hard 
surface ; the legs must then be fully extended and rotated inwards until the 
front of the lower end of the femur looks directly forwards ; the two internal 
condyles are then to be put just touching one another. A vertical line is then 
drawn through the umbilicus and centre of the pubes downwards to the level 
of the malleoli, and on measuring the distance from' the inner malleolus on 
each side to the vertical line the amount of deviation will be ascertained. In 
double genu valgum the line will, if the limbs are symmetrical, pass through 
the point of contact of the condyles, while in bow-leg it will lie far within the 
arc of the upper part of the limb, but may pass to the outer side of, or through 
the ankle. 

Knock-knee in children does not always depend upon rickets, and it is 
important to recognise this fact. It may simply be the result of lax liga- 
ments without any primary or even secondary alteration in shape of the 
bones ; thus a child may have marked ge?ni valgum while standing up, but 
on lying down it may be possible to bring the legs perfectly straight, and to 
again produce the deformity by steadying the thigh and abducting the leg ; 
a distinct gap will then be felt between the femur and tibia on the inner side, 
and lateral rocking may be easily shown. In such patients the deformity 
may after a time become permanent from stretching of the muscles and 
ligaments on the inner side and contracture of those on the outer aspect. 

A similar deformity in one of our patients was the result simply, apparently, 
of hysterical contraction of the muscles on the outer side, with weakness of 
the internal set, ' muscular spasm'' (Guerin). 

1 Other explanations have been given, such as that it is due to rotation of the femur at 
the hip (Noble Smith) ; but this is not very intelligible. Reeves gives Busch's view that 
it is due to obliquity of the axh of rotation. 2 This occurs only in severe cases. 



Rickety Deformities 417 

Treatment oj Rickety Deformities.— The degree of deformity, the age of 
the patient, and the state of the disease, whether stationary or getting worse, 
and the amount of care and trouble that can be bestowed upon the child, are 
the points to be considered in the treatment of these cases. Thus it is useless 
to attempt to treat by instruments or splints a very severe case of distortion,, 
while, on the other hand, it is rarely necessary to perform osteotomy upon a 
child under three years old because the application of splints with or without 
previous forcible straightening, if it is a case of curve of the tibia alone, will 
usually suffice for a cure. Again, if the deformity has been stationary for some 
time and it is probable, therefore, that the post-rickety sclerosis of bone has 
taken place, it is useless to think of straightening the leg without operation,, 
while if the curvature is getting worse, it is probable that the bones are still 
sufficiently soft to yield to pressure. Besides these considerations comes the 
very important one of the amount of care and time that can be bestowed 
upon the child ; it is not only justifiable, but necessary, to perform osteotomy 
upon many children who could be straightened perfectly well without operation 
if they could be seen frequently by the surgeon, be kept off their legs, and 
their splints properly applied, but who are neglected, allowed to get about 
anyhow, and their splints are applied wrongly or not at all. In such cases it 
is mere waste of time to do anything short of operation ; hence we have 
frequently osteotomised or forcibly straightened the limbs of children between, 
two and four years old, and we entirely disagree with the view that it is bar- 
barous to operate upon young children who could be straightened without 
operation if it were possible to give all alike the same care and time. At any 
rate, it is practically a choice between their remaining crooked and osteotomy 
or fracture. The general constitutional treatment of rickets has been already 
considered elsewhere. The local treatment consists in operative and non- 
operative means. 

Treatment without Operation. — In a young child with the deformity in- 
creasing, but not very severe, who can be well looked after, the treatment of 
knock-knee consists in forbidding him to stand at all, in bathing and rubbing 
the limbs well to improve their circulation and muscular power, and in using 
firm, steady traction in the direction of straightening the limb, as if to break 
the leg across the knee, for ten minutes at a time night and morning, such 
force as can be borne without pain being employed, and care being taken that 
the limb is fully extended. For the rest of the day and at night the child 
should wear a light, slightly hollowed, straight splint, long enough to reach 
from the top of the trochanter to just below the sole of the foot. This splint 
should be fixed to the upper part of the thigh and the lower part of the leg 
by inelastic webbing straps, while over the prominence of the knee an elastic 
strap should be applied to draw the knee outwards against the splint : we 
prefer this plan to bandaging only. As soon as the child's health is imprctt ed, 
or if the case is very slight, a shorter splint may be employed and he may be 
allowed to walk about wearing it. 1 [f it can be afforded, a light iron splint 
may be used instead of the wooden one ; the one figured on p. 418 is a very 
good form. 

1 We may here again remark, once for all, thai a child may get fresh air and exerc se 
without walking, and that in the poorer classes, where we chiefly find these deformit - 

is useless to attempt treatment In at all severe eases if the child walks about. 

r E 



41 8 General Diseases 

If the distortion is at all severe, a practical difficulty will be met with in 
applying and keeping on the wooden splint : it will be found that the splint 
slips round to the antero-external aspect of the limb instead of remaining 
at the outer side ; when this happens no traction is exerted upon the knee, 
and the splint is useless. In such cases, if the iron cannot be obtained, a 
back splint rather broader than the limb and as long as the outside one 
should be first applied, and then the outside splint put on with its edge rest- 
ing against the edge of the back splint ; this will be found to prevent 
rotation. The two splints can be joined together so as to make a single half- 
box splint — a plan first used, we believe, at the Victoria Hospital, Chelsea. 
Thomas's knee splint may also be used for these cases : its advantages are 
that the child can get about from the first, and that elastic traction can be 
employed with it ; its disadvantages that it is somewhat troublesome to get 
made correctly, except at the price of a guinea, and that it is somewhat 
difficult to prevent rotation in it. Many other forms of appliance may be 
bought, but those mentioned are in our opinion the best. Whatever 
splint is employed, complete extension of the limb is necessary for the 
apparatus to produce any effect. 1 For bow-leg it is only necessary to apply 
the splint on the inner side instead of the outer, and it is much easier to 
manage, since there is little tendency to rotation of the splint. Lateral 
curve of the tibia is treated in the same way, but the splint need not reach 




Fig. 79. — Thomas's splint for Genu Valgum. The pad is applied to the great trochanter and the 
spike fits into a socket in the boot. An elastic strap draws the knee outwards. 

above the knee ; the anterior curve requires a back splint with a foot-piece, 
and is more troublesome to manage, pressure being difficult to apply without 
causing pain at the heel. A simple anterior curve is, however, a much less 
serious deformity than the other, and is much more prone to improve without 
apparatus. 

Operative Treatme?it of Rickety Deformities. — Operation is required in 
patients in whom the deformity is severe, in those who have recovered from 
the rickety process and whose bones are sclerosed, and in those who cannot 
be well looked after or submit to prolonged treatment. 

Operative measures are of three kinds : fracture after partial division of 
the bone with saw or osteotome, forcible straightening without external wound, 
and straightening after tenotomy, &c. In cases of curvature in the shafts of 
the tibia and fibula at the lower part of the leg in young children, before 
sclerosis has occurred, we consider forcible straightening a good and simple 
plan, resulting in a green-stick fracture just at the curve. It is, in any case, 
suitable for it, easily done by taking the child's limb in one hand just above, 
and in the other just below, the deformity, taking care to have hold of the 

1 Hueter treats genu valgum by simple flexion, and Little thinks well of it, but suggests 
sitting a la Ttirque as useful. 



Osteotomy 419 

tibia and fibula, and not of the foot, otherwise the strain would come upon 
the ankle joint ; the limb is steadily and forcibly bent straight by the hands ; 
a certain amount of jerking is, however, sometimes useful. Tenotomy and 
subsequent straightening in cases of genu valgum we look upon as highly ob- 
jectionable : it weakens the joint and only temporarily straightens the limb. 1 
As to forcible straightening in cases of genu valgum, we have strongly 
•condemned it in former editions, but having asked Mr. Murray of Liverpool 
to give his experience, he writes thus : 

During the last three years I have practised somewhat extensively a method of treat- 
ment that was recommended by Professor Ogston at the Glasgow Meeting of the British 
Medical Association — viz. immediately and forcibly correcting the deformity, and then 
applying the splints. I have thus straightened more than four hundred knock-knees, and 
have every reason to be well satisfied with this line of treatment. But in speaking of 
•osteoclasis for genu valgum, I wish it to be clearly understood that I practise it chiefly as 
a substitute for splints, and consequently refer only to the treatment of this deformity as 
it occurs in quite young children, that is to say, in children under five years of age, or in 
those a year or two older who are markedly rickety. 

Many surgeons, I believe, practice osteoclasis for curved tibiae, but comparatively few 
do so for knock-knee. The objection, it is said, being that in so doing you p'roduce 
a separation of the lower epiphysis of the femur, and so may interfere with the subsequent 
growth of the limb. Now I have on several occasions forcibly straightened a knock-knee 
on one side only, and have examined the children eighteen months afterwards, and found 
absolutely no difference in the length of the limbs. And further, at the time of operation, 
I examine for the seat of fracture, and find that it almost invariably takes place at a point 
where the lower end of the femur joins the shaft, and quite an inch above the epiphyseal 
line. 

My hands are the only osteoclasts I have ever used, and in forcibly straightening 
a knock-knee (say that of the right side), standing to the right of the patient, the child of 
course being under chloroform, I grasp the thigh firmly with my left hand about two 
inches above the patella, using my index finger supported by my other fingers as a 
fulcrum, and hold the thigh perfectly steady with this hand; then, with the right hand 
grasping the leg just above the ankle, gradually straighten the limb, the knee joint being 
kept over-extended the whole time. 

After osteoclasis I put the limb in plaster of Paris which is kept on for a month ; the 
plaster is then removed and the child kept off its feet for a further period of six weeks, 
after which it is allowed to run about, constitutional treatment being, of course, adopted 
from the first. 

There is no doubt that in children over four years of age considerable force is some- 
times necessary ; if, however, in attempting to forcibly straighten a crooked bone one has 
to use so much force as to render it uncertain where the fracture will take place, then you 
had better desist and perform an osteotomy. 

Mr. Murray, in addition to writing the above account, has been good 
enough to come over and show us his modus operandi, and we must admit 
that, strictly within the limitations of age and rigidity of bone that he 
mentions, and provided his exact method is followed, we are convinced that 
the operation is safe and practicable ; but Mr. Murray's method must be 
absolutely followed, and the exact site of the fracture determined ; : .t is not, 
moreover, every surgeon who has Mr. Murray's skill. Other methods o\ 
treatment do not require further notice. 

osteotomy. — The general principle of an osteotomy is to partially divide 
with a saw or chisel the shaft of the bone in the neighbourhood of the 

1 Vide Lannelonguej Le Bull, .1A\.\ ; also In \ah S 



420 General Diseases 

deformity through a small wound, then to complete the fracture, straighten 
the limb, and treat it like an ordinary compound fracture. 

Of the various operations devised by Ogston, Macevven, Chiene, Reeves, Schede, and 
others, for remedying genu valgum, in our experience that of Macewen and the section 
of the femur above the condyles by means of a saw from the outer side are the best. This 
plan was, we believe, first employed by our colleague Prof. T. Jones. We occasionally 
do an Ogston's operation, but supracondyloid osteotomy with a fine Adams' or keyhole 
saw is, we think, the most generally useful method. Ogston's plan should be limited to 
those cases where the deformity is entirely due to condylar overgrowth. It is very seldom 
employed. In the case of osteotomy of the tibia we prefer to saw through the tibia and 
fracture the fibula forcibly, or, if that cannot be readily done, we divide the fibula with an 
osteotome through an incision on the outer side of the leg. 

After straightening the limb we put it up in a back and side splint, inner or outer, 
according to the deformity, or in a Macewen's splint, and leave it for a week ; at the end 
of that time we take it down and mould it accurately into position under chloroform : 
the callus is soft and moulds easily ; the limb is then ready for a plaster of Paris splint, 
which should be kept on for three or four weeks and then taken off, and the limb welt 
rubbed, the joints flexed, and then the splints replaced for another week ; after that the 
child may be allowed gradually to put his weight upon it. In heavy children an extra 
week should be given, and a light wooden splint worn for another month or so. It is a 
good plan to put on a Thomas's knee-splint after the first month, or even sooner. 

In severe cases of tibial curve, especially of anterior curvature and in some of those at 
the upper part of the leg, the deformity cannot be remedied by a simple section, but re- 
quires the removal of a wedge of bone ; this is a very much more serious operation, and 
one that we think should not be performed for the anterior curve alone, for besides its 
severity it does little to remedy the distortion unless a great amount of bone is taken away, 
and the tendo Achillis divided as well. This anterior curve is also much less important 
than the lateral one. If osteotomy is required in such a case, the oblique section of Gowan 
is probably the best. 

Osteotomy is a simple operation in most cases, but it has its dangers and its mortality. 
The popliteal artery has three times been wounded, severe bleeding has also occurred from 
the anastomotica magna, death has followed in some few cases, and gangrene of the leg 
in one at least — a case of our own, in which we removed a wedge from the upper part of 
the tibia. " In this, our only serious casualty, no vessel was wounded, but either from 
pressure of the bones in their altered position, or from the splints being put on too tightly, 
the limb had to be amputated subsequently. There is no comparison between simple 
section and excision of a wedge in severity. For details of the various operations we 
must refer to the orthopaedic and general surgical works. 

Drilling holes in the bone and subsequent fracture, with modifications of this plan, 
have, we think, no advantages over the saw and osteotome ; which of these is used is 
nearly a matter of indifference. 

Multiple osteotomies, i.e. section of femur and tibia at one or more points, are some- 
times required ; when this is so we prefer to do one at a time on each limb, though Mac- 
ewen has many times done several with perfect success. Deformities of the fibula alone 
from rickets are never important. 

Osteotomy of the femur with a saw from the outer side is best performed by placing 
the limb upon a sand pillow, with the knee slightly flexed, and making a puncture with a 
large tenotome on the outer side of the limb, just in front of the border of the tensor 
vaginae femoris, and a finger's breadth above the level of the adductor tubercle. The 
knife is then carried across the limb, keeping as close to the bone as possible, taking care 
not to thrust it through the skin on the inner side. In this part of the incision the blade 
should be held flat, i.e. in the same plane as the surface of the femur ; as soon as the 
inner side of the limb is reached the knife is turned with its edge against the bone and 
withdrawn. It should during withdrawal be gently pressed against the bone so as to 
divide the periosteum and form a track for the saw. As soon as the knife is taken out of 
the wound the narrow saw is thrust sharply with a jerk into the skin wound and its point 



Lateral Curvature of the Spine 42 1 

made to strike the femur ; it is then carried readily over the front of the bone and its 
point felt beneath the skin on the inner side. The limb is well steadied and the bone 
.sawn ; care being taken to saw at right angles to the axis of the femur. In sawing, the 
hand should be tilted, so as to divide mainly the outer and front parts of the shaft, until 
nearly the whole thickness is sawn through. It is a matter of experience how far to saw 
— usually about two-thirds of the way through is sufficient ; a useful guide is the depth 
■of the saw from the front of the bone as felt through the soft parts. When the bone is 
nearly divided the saw is withdrawn, the thigh steadied by the hand nearest the patient's 
trunk, and the limb bent inwards by adducting the leg with the other hand. The bone 
sometimes snaps sharply and sometimes yields : in the latter case sclerosis has not 
probably gone so far, and the fracture is more or less green-stick. One of our house 
surgeons remarked that the patient had less pain after these yielding fractures than when 
the division was complete, no doubt because there was no complete separation and less 
mobility of the fragments. 

Should the saw have been withdrawn too soon, and it is found impossible with reason- 
able force to fracture the limb, it is usually easy to reintroduce the saw and divide the 
bone further : the groove already made is usually found without much trouble ; failing 
this, the best plan would be to enlarge the opening and divide the bone with an 
•osteotome. 

Section of the tibia is done in the same way, the puncture being made over the anterior 
border of the bone at the line of greatest curvature. It is usually possible to fracture the 
fibula ; if not, it should be divided with an osteotome through an incision over it. Mac- 
ewen's operation we need not describe, as for general use we prefer the method already 
mentioned, but we may say it consists in incomplete section of the femur with a graduated 
osteotome from the inner side, through an incision in the soft parts. His guides are ' a 
line drawn a finger's breadth above the level of the upper border of the external condyle, 
and a line drawn parallel to and half an inch in front of the tendon of the adductcr 
magnus.' The point of intersection of these lines is to be the centre of the incision. In 
none of these operations is any ligature or suture required, and antiseptics should be 
rigidly carried out. The wound in the soft parts is healed usually in a week, or a point 
•of superficial granulations alone remains, and it is only occasionally that the dressings 
require changing from oozing of blood. It is well to squeeze all the blood out of the 
•opening before putting on the dressings. 

The deformity resulting from non-apposition of the fragments after these operations 
gets modelled down after a few months just as in a fracture. Oblique section of the bone 
as in a splice, a plan suggested by Mr. Gowan, is sometimes worth trial ; it causes less 
immediate deformity, but is somewhat more difficult to manage. 

lateral Curvature of the Spine. — This affection in its most common 
form is a disease rather of early adult life than of childhood, being seldom 
found before puberty, hence only the more important features will be con- 
sidered here. There are, however, certain forms of scoliosis that belong to 
childhood more particularly : such are the rickety lateral curvatures and those 
due to empyema or unilateral limb-shortening, as well as, of course, the con- 
genital cases. It must be remembered that in infants the normal curvatures 
of the adult spine do not exist. 

It is now well recognised that the deformity is a compound one, that there 
is never a pure lateral curve without rotation, nor pure rotation without a 
lateral curvature, although it may in some cases require close observation to 
verify this, and the more so (hat rotation conceals to a greatei or less extent 
the deviation of the spinous processes by bringing them nearer the middle 
line. 

As soon as any lateral bending in one segment ol the spine occurs, two 
things necessarily happen if the child maintains the erect posture : first, 



422 General Diseases 

compensatory curves must take place in the other parts of the spine to 
balance the primary curve and maintain equilibrium ; next, the obliquity of 
the articular processes, and in the dorsal region the powerful rotation action 
of the ribs when they are approximated, must result in rotation of the 
vertebras upon a vertical axis. 1 Hence in a case of a lateral curvature we 
almost always see compensatory curves in the opposite direction, and in- 
variably more or less rotation ; the term rotato-lateral curvature is therefore 
the more exact title. Scoliosis is convenient as a short synonym. Scoliosis 
in children may be the result of — 

i. Congenital malformation of the spine, in which imperfect segments 
of vertebral bodies are intercalated on one side of the spine only. (Bland 
Sutton, 'Med.-Chir. Trans.' 1884.) 

2. Congenital [deficiencies in the limbs of one side, so that the action of 
the muscles and the weight of the normal limb are unbalanced. 

Occasionally scoliosis is secondary to the form of congenital torticollis 
which is due to malposition in utero. 

3. Shortening of one leg from any cause : for instance, a flexed, anchy- 
losed hip or knee gives rise to shortening and compensatory scoliosis. 

4. Imperfect development or sinking in of the chest- wall on one side, as 
in atelectasis or empyema. 

5. Muscular and ligamentous weakness combined with faulty attitudes. 

6. Rickets. 

7. Caries, especially if one side of the bodies only is involved. 

Various other types of scoliosis have been described, but they may all be 
practically grouped under one or other of the above heads. 

The mode of production of rotato-lateral curvature by the above causes 
is obvious except in cases of Group 5, of which a word or two more must 
be said. It is usually stated that this form of scoliosis is a disease of the 
upper classes, and is found in girls who loll about or sit in ungainly attitudes 
for long hours, writing or working, during their most active period of de- 
velopment, while at the same time no sufficient exercise is given to their 
muscles. While it is true that weak spines or slight degrees of curvature 
are often thus produced, the disease is common enough among the poor, 
and, as it is usually neglected in its earlier stages, is seen in much worse 
degrees. It is also not rarely found in muscular, well-developed people in 
early adult life. It is, moreover, at times produced in young girls by carry- 
ing heavy babies or other burdens too great for them. 

The whole spine should in all cases be carefully examined with the patient stripped, 
and the back should be inspected in different positions of curvature and of the limbs, 
the course of the spines and the level of the scapulas and iliac crests being noted. 

If a weak or tired spine is examined with the patient stripped and 
standing or sitting upright, it will perhaps be seen at first to be held fairly 
straight, but often after a minute or two the weight is thrown to one side, the 
lumbar vertebrae curve with their convexity towards that side, and a 
compensatory dorsal curve appears with its convexity to the opposite, 
usually the right, side, while a slight alternating curve in the cervical region 

1 Judson of New York attributes the rotation to the fact that the ribs are attached to 
the spine behind the bodies — the latter, as it were, are free in the thoracic cavity, and there- 
fore liable to rotate, while the spines form part of the thoracic wall. 



Lateral Curvature of the Spine 



423 



is sometimes readily seen. At the same time flickering contractions of the 
spinal muscles as they become tired are often visible. In an early case all 
these bends can be straightened out by an effort of the patient, or by 
bending forwards or by lying down. If, however, the patient is neglected 
the curves tend to become permanent, for the weak muscles become con- 
tractured on the concave side, the ligaments become shortened, the inter- 
vertebral discs thinned and compressed, and the shape of the vertebral 
bodies and articular surfaces at last altered. But while this is going on the 
vertebrae rotate upon a vertical axis so that the bodies come to face towards 
the convexity of the curve, and the ribs become bent in such a way that there 
is a sharply convex bend backwards close 
to their angles on the same side : this pro- 
duces a prominence also on the convex 
side, while in front, in order as it were to 
reach the sternum, the ribs are usually 
more or less flattened and straightened out. 
The converse of all this takes place on the 
opposite side of the spine. There is still a 
further change resulting from this : the 
scapula on the convex side is pushed out 
by the bulging ribs and projects backwards, 
while it is raised or lowered above the 
level of its fellow according to the exact 
seat of the curve ; this is so marked that 
' growing out of the shoulder ' is usually the 
first-noticed sign and the popular name for 
the affection. The scapula on the concave 
side also often projects sharply backwards 
and towards the mid-line, since it cannot 
rest evenly against the flattened chest wa'l 
{vide fig. 80). A projection of the hip on 
one side or the other according to the 
curve will also be noticeable. 

All degrees of deformity may be met 
with, from the mere weak spine, with no 
permanent curves, but with a tendency to 
collapse in any direction, to deformity, 
where the ribs on one side are overlapping 

one another and lying within the crest of the ilium, while the whole trunk is 
distorted and misshapen. Sometimes an anteroposterior curve (kyphosis) 
coexists with the scoliosis, and it is very important not to be misled by this ; 
still more important is it to remember that in cases of caries there is some- 
times a lateral curvature before any angular curve appears : this may occur 
either in caries of the bodies or, as pointed out by Reeves, where there is 
disease of the articular processes or costo vertebral joints. The diagnosis is to 
be made by noting the rigidity o( the spine and usually the greater severity of 
the pain in the case of caries, as well as by the history o\ the patient The 
exact position of such curve is by no means constant, and. though a curve 
convex to the left in the lumbar and convex to the right in the dorsal region 




Fig. 80. — Lateral Curvature of the Spine. 



424 General Diseases 

is the commonest condition, the lower curve may be dorso-lumbar or the 
sides may be reversed, and so on. This, of course, depends largely upon the 
cause of the curvature ; thus in empyema the amount and position of the 
collapse will determine the curve. Sometimes, especially in rickety cases, 
and probably in those due to partial atelectasis, the curvature is local and 
the compensatory curves are so slight and diffuse as to be nearly impercep- 
tible. In some cases curvature of the spine is to be looked upon as compen- 
satory and advantageous, and not as a morbid condition : such are slight 
curvatures which make up for inequality in the length of the limbs and the 
slighter degrees of curve due to empyema ; thus in one case the curve may help 
to hide the deformity and in the other assist in filling up a suppurating cavity. 

Aching pain of greater or less severity, and a general feeling of tiredness, 
with depression of spirits and tonelessness, are the principal subjective 
symptoms of lateral curvature. The pain is usually in the side and not in 
the back or chest and abdomen. 

Treatment. — Scoliosis due to congenital malformation of the spine itself 
or to deficiency of an entire limb, as well as that due to collapse of the chest- 
wall after empyema or severe atelectasis, is necessarily not entirely and in 
many cases not at all remediable, while curvature due to rickets, weakness, 
bad habits, or a shortened leg may in its early stages be entirely cured and 
in almost any stage prevented from getting worse. 

In any case the aim must be to first remove the cause tending to increase 
the deformity, to improve the general health, to strengthen the muscles and 
ligaments, and to avoid pressure and strain upon the weak parts. In the 
rickety scoliosis of 3'oung children the rickets must be treated and the child 
never allowed to remain sitting up for any length of time ; its general posture 
must be flat upon its back or face, or upon its side, with pillows so arranged 
as to straighten out the curves. The principle is not to keep the patient 
lying down, which would of course in no way strengthen the muscles, but to 
give the parts just such exercise as will make them develop, and in the 
intervals give them complete rest. 

Fresh air, friction to the spine, with frequent change of position and proper 
diet and medicine, will readily cure any case in which there are no fixed 
curves, while in the more severe cases in older children the same treatment 
must be adopted. In an ordinary case, the result of weak muscles and joints, 
and improper postures, the lines of management are to avoid tiring the 
muscles and ligaments, and yet to strengthen them by exercise ; to avoid the 
postures which have produced the deformity ; to counteract their effect by 
opposite positions, thus stretching contractured muscles and ligaments, &c. 1 1 
is impossible here to enter into details of the various exercises required or of 
the different apparatus recommended, but it may be said that in addition to 
all means of strengthening the health and improving the tone of the muscles 
— friction, salt-water douches, general exercise, and so on — a careful examina- 
tion should be made with the child stripped entirely to see what positions 
and movements tend to correct the deformity, and these should be made the 
subject of regular practice at intervals through the day. A reclining board 
such as that figured (fig. 81), or some similar one, horizontal bars, trapezes, 
dumb-bells, Sayre's suspension apparatus, and so on, are all useful as means 
of strengthening the muscles. 






Lateral Curvature of the Spine 



425 



Regular walking exercise for frequent short periods should be taken, the 
patient lying down afterwards, and constant watchfulness to correct any 
tendency to loll must be observed. Busch's plan of making the patient lie 
prone, with the chest and head over the end of a couch, then bending down- 
wards and raising the front half of the body against gradually increasing 
resistance, is a good method of exercising the spinal muscles. Bending 
the body forward with the knees straight and trying to touch the toes with 
the hands, then recovering and bending backwards with the head well thrown 
back ; keeping head and shoulders back and leaning towards side of greatest 
convexity, then recovering upright posture ; lying down with large hard 




Fig. 81. — Reclining Board for Lateral Curvature, with Extension Apparatus for the Head and 
Arms. The head straps have been omitted for clearness, and only part of the couch is shown. 
Both head and hand straps are fitted with india-rubber accumulators. 

pillow or Barwell's sling under the convexity of the ribs ; raising the arm 
on concave side and pulling the body up by it by means of horizontal bar or 
trapeze ; all these are good movements. For private patients much time 
is saved to the surgeon and expense to the patient by instructing a professed 
masseuse or gymnast to carry out such manipulations as the surgeon may 
oider. 

It is a good plan to let the patient sleep in a Barwell's sling or out .1 hard 
pillow under the convexity of the chest ami remove the one under the head, 
or substitute a thin one for it. Of forcible ' redressement J we have no 
experience, but careful moulding of the deformity with the hands is worth 
doinsr. 



426 General Diseases 

All spinal supports are to be reserved for cases where the deformity is 
extreme or rapidly increasing, and must be used with the greatest caution 
and never relied upon except in conjunction with the exercises and other 
means already indicated. As a means of treatment alone they are as harm- 
ful as in caries they are useful. No cases of lateral curvature must ever be 
given up to the care of an apparatus maker. For details as to spinal 
supports, modes of measuring the deformity <5:c. the works of Reeves and 
others may be consulted, but, as a rule, the less supports are used the 
better. 

Antero -posterior Curvature. — Occasionally cases of antero-posterior 
curvature (kyphosis) are met with in children, both in infants and in those 
of older growth. These must be distinguished from the common rickety 
kyphosis. They give rise to an appearance closely resembling the stooping 
and bent-back of old age, and may be mistaken for cases of caries. Absence 
of rigidity and pain, and of evidence of rickets will usually enable these cases 
to be recognised, but it is well to watch them closely for a considerable time 
before assuming that there is certainly no caries. Exercises and a suitable light 
steel support are the best means of treatment. 

Note. — The subject of ' Flat-foot' is, for convenience sake, considered in the chapter 
on * Club-foot.' 






427 



CHAPTER XIX 

SYPHILIS 

Infants and children may suffer from syphilis acquired in various 
ways after birth, or they may be the subjects of hereditary syphilis, the 
virus in this case being received from one or both parents during intra- 
uterine life, or the infant may be inoculated with the syphilitic poison at the 
time of birth. 

Acquired Syphilis. — Can a healthy infant be syphilised by means of 
the milk of a wet-nurse ? This is an important question, and one which is 
often asked by parents before a wet-nurse is employed ; there is no evi- 
dence that we know of to show that it can, and there is a strong probability 
that even if the virus was present in the milk it would not inoculate the infant 
unless introduced directly into the blood. That the infant can be inoculated 
if it have an abrasion on the lips and it draws blood from a sore nipple of a 
nurse suffering from secondary syphilis is certain, and it may, of course, be 
inoculated by the discharges from the genitals of the nurse conveyed to it 
on the nurse's hands. It need hardly be said that in selecting a wet-nurse 
the most scrupulous care should be exercised in ascertaining that the would- 
be nurse is not suffering from any specific disease, a careful inquiry being 
made as to her health and the health of any children she may have had, 
especially with regard to any symptoms of syphilis. 

Children of various ages may be seen in dispensary practice suffering 
from chancres on the lips and genitals, who have been inoculated from their 
parents or others having specific sores, the virus being perhaps conveyed on 
the fingers. It is important to bear in mind that not only are the discharges 
from a primary sore liable to inoculate, but the discharges from various 
secondary lesions both in acquired and hereditary syphilis may also infect. 
Thus infants suffering from coryza or specific ulcerations about the mouth 
may inoculate the breast of a healthy wet-nurse, though they apparently 
never do that of their mother. No syphilitic infant should be wet-nursed by 
any one except its mother. 

Syphilis has undoubtedly been on rare occasions inoculated by means o( 
vaccination : abundant evidence of this exists in some epidemics ot syphilis 
which have occurred, though such an accident is exceedingly rare, especially 
when we remember the frequency with which vaccination is done and the 
certainty with which such an accident is discovered. It may often happen 
that when vaccination is performed it is followed in a few days or weeks by 
symptoms of secondary syphilis, such as a roseolous rash, coryza, &c.,but in 
the absence of a primary sore at the seat of vaccination these syphilitic 
manifestations cannot be accepted as evidence o( vaccino-syphilis, and 



.428 Syphilis 

evidence may most probably be obtained of syphilis in the parents or in 
some of the brothers or sisters. As the first symptoms of hereditary syphilis 
most frequently make their appearance at from six weeks to three months 
after birth, and as this is the usual time for vaccination, it is highly probable 
that vaccination and the secondaries will often exist together and yet have 
no connection. If syphilis has been inoculated by vaccination, a month or six 
weeks later — during which time perhaps the vesicles have imperfectly healed 
— an induration makes its appearance at the seat of one or more of the 
vesicles, or there is an ulcer with an indurated base which has the characters 
•of a hard chancre ; this remains indolent, crusts over, and is followed in the 
-course of a few weeks more by a specific eruption and other specific pheno- 
mena. In any case where vaccino-syphilis has taken place a well-marked 
scar is left at the seat of the puncture where the hard chancre has formed. 

It is important to remember when investigating any case of supposed 
vaccino-syphilis that an interval of a month or six weeks elapses between 
vaccination and the formation of a chancre at the seat of inoculation 
(Hutchinson), and the diagnosis of syphilis cannot be accepted unless this is 
the case. 

Hereditary Syphilis. — In hereditary syphilis the foetus receives the 
poison at some period during intra-uterine life, and may be born with the 
evidence of syphilis on it, or it is born healthy, the specific symptoms making 
their appearance within a few weeks or months of birth. In these cases, 
unlike acquired syphilis, there is no primary sore. The part played by the 
father in transmitting syphilis to his progeny does not admit of a doubt : the 
more recently he has suffered, the more likely is he to transmit it in a severe 
form, though for many years he is liable to beget children who suffer from 
hereditary syphilis. The most usual way in which he transmits it is by 
means of the spermatozoa at the time of fertilisation of the ovum ; or during 
the intra-uterine life of the foetus the mother may become infected by the 
husband, and she may infect the foetus through the placental circulation, though 
this appears to be rare during the later months of intra-uterine life. The 
mother may transmit the disease to the ovum or the foetus in utero, but this, 
.as just stated, is rare after the seventh month of foetal life ; or she may infect 
it during the act of birth. The mother, on the other hand, may apparently 
be infected from the foetus, though often she appears to escape ; that is, a 
syphilitic father infects the foetus, the child is born and suffers from syphilis, 
the mother apparently escaping ; but the escape of the mother is more 
apparent than real, inasmuch as such women appear to be insusceptible to 
syphilis, and there is reason to believe that they do not escape, though the 
attack must certainly be slight. (' Colles' law.') 

A. Baginsky gives the following summary of the etiology of congenital 
syphilis : 

(1) If the father and mother are both syphilitic, a syphilitic infant is 
generated, or the mother may miscarry ; the more severe and recent the 
syphilis is in the parents, the more likely is the foetus or infant to suffer 
severely. 

(2) If the father is syphilitic and the mother healthy, the infant maybe 
syphilised at the time of conception, and this may happen when the father is 
affected by tertiary as well as secondary syphilis. Under these circumstances 



Hereditary Syphilis 



429 



•the mother may be syphilised either through the spermatozoa or from the 
foetus through the placental circulation ; she may apparently escape, but such 
women cannot be inoculated. 

(3) If the mother only is syphilitic the children may escape ; certainly 
mothers with tertiary symptoms may bring forth sound children. 

(4) If the father and mother are healthy at conception, and the mother 
becomes affected during pregnancy, the foetus becomes infected through the 
placental circulation ; an infection during the act of birth is possible. 

Effects of the Poison on the Foetus. — The mother may miscarry at any time 
during fcetal life, a result due to disease of the foetus or placenta ; this is 
especially likely to happen if the father and mother are suffering from the dis- 
ease in an active form. The exact nature of the lesions is uncertain : the 
placenta and internal organs, as the liver, lungs, &c, have been found diseased. 
The infant may be born at term, but dead, or may survive its birth but a short 
time ; in the latter case it is puny, shrivelled, with blue extremities and a feeble 
hoarse cry. It may suffer from various skin eruptions, the most common (in 
the newly born) being pemphigus ; various internal lesions maybe found, such 
as interstitial hepatitis, and there may be gummata, perhaps breaking down, 
in the thymus, heart, or lungs. It may exhibit a tendency to bleed (see p. 26). 

Symptoms a7id Course. — The first definite symptoms usually make their 
appearance during the second month of life. These are often preceded by 
more ill-defined symptoms, such as restlessness, fever, peevishness, diarrhoea., 
and dyspepsia. The in- 
fant suffers from what 
appears to the friends to 
be a cold in the head : 
the nasal passages are 
obstructed by excessive 
secretion and the infant 
' snuffles ' during inspira- 
tion ; in the more severe 
cases the breast is taken 
with difficulty, as respira- 
tion is impeded during 
sucking on account of the 
nose being blocked, and 
the infant has to stop to 
breathe through its mouth. 
The coryza is followed 
by a characteristic rash, 
which usually consists of 
an erythema or erythe- 
matous patches of various 
sizes, the favourite places 
being about the anus, ge- 
nitals, thighs, and forehead. Instead of an erythema the rash may be 
papular. When the eruption appears first it is a bright red, the vividness fades 
in a day or two, and the skin desquamates, and becomes of a dull red or 
coppery hue. As the disease progresses the secretion oozing from the nose 




'ig, 82. Fissures around the Mouth in .1 case of Congenital 
Syphilis. The « hole appearance of the face i> characteristic 



43° Syphilis 

dries up and forms scabs, the entrance to the nostrils becomes sore, and per- 
haps a sanguineous purulent secretion escapes from time to time. The upper 
lip may become excoriated and scabbed over. The corners of the mouth, 
which are constantly moist from the excess of saliva, become raw and per- 
haps ulcerated ; fissures and scabs may form which heal but slowly, leaving 
radiating scars (figs. 82, 83). 

The mucous membrane of the larynx may become affected, being swollen 
and perhaps ulcerated, and the child in consequence has a hoarse cry ; there 
may be marked anaemia and wasting, so that the child shrivels up and be- 
comes reduced almost to a skeleton. 

Infants occasionally die at this period, apparently from the intensity of 
the poison. This seems to have been so in the following case — o\xx post- 
mortem notes are as follows (the child was not seen during life by any medical 
man) : 'The mother states the infant, which was seven weeks old, "snuffled" 
a week before its death, and three days before a reddish rash appeared on 
the buttocks and around the mouth. It was found dead in its cot. At the 
autopsy the infant was fairly well nourished, there was a purulent discharge 
issuing from its nose, the skin around the mouth and nose was excoriated, 
apparently from the nasal secretion, and there were some excoriations and 
redness around the anus. The whole of the mucous membrane of the nose 
was in a foul, almost sloughy condition, the surface being dark-coloured and 
covered with muco-pus. On one tonsil there was a deep ulcer ; there was 
no laryngitis ; all the other organs in the body were healthy.' 

While in the more severe forms the infant is the colour of cafe an /ait, 
wizened and wasted, other infants may be seen who are plump and ruddy, 
yet who are undoubtedly syphilitic, and who subsequently develop a typical 
rash. In some who suffer later from syphilis no history can be obtained of 
coryza or rash, and we are driven to the conclusion that the secondaries are 
sometimes so slight as not to attract the attention of the friends, and may 
■even deceive the medical practitioner. The mortality of syphilitic babies is 
high ; not only is the effect of the poison depressing, but the blood seems to 
be profoundly altered, the digestive organs are interfered with, and the infant 
wastes and dies. ' Congenital syphilis] ' mal-nntrition ' is written on the 
death certificate of many syphilitic babies. 

On the other hand those who suffer in a less severe form and come under 
treatment early rapidly improve, gain flesh, and for a time at least all sym- 
ptoms disappear. While such cases may apparently be entirely cured yet, 
like the secondaries which occur in adults, the symptoms are very apt to re- 
appear, especially during the second and third year. This relapsed syphilis 
may make its appearance in children in whom the symptoms following birth 
are slight, and consequently what is really relapsed syphilis is very apt to be 
mistaken for acquired syphilis. This recurrence usually takes the form of 
condylomata or ulcerations about the anus or tongue, and chronic fissures 
about the corners of the mouth and nose ; various rashes may also be present. 

During the next few years the child may remain fairly well, but on the 
approach of puberty symptoms which correspond to the tertiaries of adults 
may make their appearance. Children at this period often bear the marks 
of past lesions, and if seen for the first time there may be no difficulty in 
recognising them as subjects of congenital syphilis, as their flattened noses 



Hereditary 



43 1 



and linear scars at the angles of the mouth, and typical pegged teeth, give 
them a characteristic appearance (fig. 83). They are apt at this time to 
suffer from periostitis, caries of bone, chronic ulcerations, ulcers of the 
mucous membrane covering the hard palate, which may involve the bone ; 
ulceration and destruction of the soft palate ; various affections of the eye, 
as iritis, keratitis, choroiditis ; various skin diseases, as ecthyma, rupia, &c. ; 
gummata in the superficial structures, and also in the liver and other internal 
organs. Deafness and partial dementia may be present, the latter accom- 




Fig. 83. — Congenital Syphilis, showing flattening of bridge of nose, scars around 
mouth, and keratitis. 



panied by syphilitic arteritis of the brain. In the worst cases the child may 
suffer for years from disease of one or other of the bones (figs. 84, S$, 86). 

Having sketched the course of the disease, we may now proceed to 
describe some of the phenomena presented by congenital syphilis more in 
detail. 

Skin. — Pemphigus is one of the most characteristic of the syphilitic rashes, 
and when present at birth may be taken as certain evidence oi hereditary 
syphilis. The seat of the blebs in syphilitic pemphigus is the palms o\ the 
hands and soles of the feet, but they ma)- be present also on the extremities 
and trunk ; their contents arc purulent or sanguineous : they may be suc- 
ceeded by deep ulcers. According to Roger non-specific pemphigus i- -.are 
before three years o\~ age and most common after six years : the bleb- are 
rarely numerous, do not occur on the palms o( the hands or soles oi the 
feet, and contain serum rather than blood or pus. The prognosis is bad in 
syphilitic pemphigus if the infant is born with the rash : as a rule, the later 



432 



Syphilis 



it appears, the better is the prognosis. The commonest rash in hereditary- 
syphilis is a roseola, which may take the form of a bright-red diffuse rash 
with a sharply defined edge surrounding the genitals, with perhaps patches 
of similar redness about the body or face, or there may be roseolous spots 
or maculae about the body, with a more diffuse rash on the soles of the feet. 
Its colour is at first a vivid bright red ; in a few days it fades, becoming 
more of the tint of lean ham ; the affected part then desquamates, leaving 
the skin smooth, shiny, and dry. The rash may be visible for weeks, 
assuming in its later stages a coppery colour. Instead of the roseola, the 
rash may consist of papules of a bright red colour, which are confluent 
about the genitals and buttocks, but scattered irregularly over the body. The 
rashes most likely to be confounded with a syphilitic roseola are those so 
commonly present about the genitals of infants, especially those produced 

in dyspeptic children by the irrita- 
tion of faeces and wet napkins. The 
difficulty of diagnosis is only likely 
to arise in the absence of a charac- 
teristic rash in other parts of the 
body, or of coryza. It is needless 
to say that a red rash with excoria- 
tions and signs of irritation about 
the anus and genitals may occur in 
both syphilitic and non-syphilitic 
children, and no rash in this situa- 
tion should be regarded as specific 
without confirmatory evidence else- 
where. Psoriasis, or scaly rashes, 
vesicles, pustules, and ecthyma, may 
occur in syphilis in infancy. Simple 
psoriasis rarely occurs before the 
third or fourth year, while syphilitic 
scaly rashes are not uncommon in 
early childhood, on the plantar and 
palmar surfaces, and on the face. 
Pustules followed by deep ulcera- 
tion are not uncommon in cachectic 
children apart from the effects of syphilis ; thus occasionally in chicken-pox 
the vesicles are succeeded by pustules or bullae, and a deep ulceration is 
produced. In making a diagnosis several points must be borne in mind : 
syphilitic rashes mostly affect the genitals, palmar and plantar surfaces, and 
face ; they are usually bright red at first, then dull red and more or less of 
a coppery hue ; they are followed by free desquamation, and they cause no 
itching. Different varieties may be associated together. 

Mucous patches and condylomata when present are of great diagnostic 
value ; they may occur at all ages, but are especially common in relapses in 
children of two or three years of age. Their common seat is around or by 
the side of the anus, vulva, fold of the groin, corners of the mouth, entrance 
to the nares — less commonly the folds of the neck. They form where there 
is some irritation, where a surface of skin is fretted by some discharge and 




Fig. 84. — Complete Destruction of the Nose, 
Upper Lip, and part of the Jaw in Congenital 
Syphilis, in a boy aged 10 years. 



Hereditary Syphilis 



433 



"kept constantly moist. Mucous patches may be present on the side of the 

tongue and soft palate. 

Coryza is perhaps the most constant symptom present. The mucous 

membrane of the nose is swollen and congested, respiration is carried on 

with difficulty on account of the obstruction. The infant is very restless at 

night, waking at short intervals to get its breath. Later on a purulent dis- 
charge tinged with blood makes its appearance, which frets and irritates 

the skin in the neighbourhood, and 

ulcers and crusts form along the upper 

lip and side of the nose. Caries of the 

nasal bones may take place ; there 

may be a discharge of pus, which 

makes its appearance down the nose 

and at the corners of the eyes. 

Lesions of internal organs. — Parrot 

bas pointed out that an ulceration due 

to syphilis occurs occasionally near 

the median line inside the lower 

lip ; serpiginous ulcers occur on the 

tongue ; inside the lips, near the cor- 
ners of the mouth, on the gums and 

soft palate ; they are mostly shallow, 

with a red and shiny base, surrounded 
by a raised, whitish, irregular border. 

Less often they are deeper and of a 
yellowish tinge. A peculiar desqua- 
mation of the tongue has been de- 
scribed. Deeply cut ulcers make 
their appearance on the hard palate 
in tertiary syphilis, the bone is quickly 
affected, and a communication with 
the nasal cavity established. A deep 
ulcer may form on the soft palate, 
and shortly a sharply cut hole be 
seen right through the Velum palati. 
Laryngitis, mucous tubercles, and 
ulcerations along the edge and at the 
base of the epiglottis, occur, but 
specific lesions of the larynx are less 
common in children than in adults. 
Specific lesions of the lungs are not 
common, though syphilitic infants frequently die of broncho-pneumonia. In 
the lungs of infants born dead, or dying soon after birth, uunun.ua and 
fibroid indurations may be found, and a form of chronic pneumonia winch 
has been described as white hepatisation by Virchow. Patches of white 
hepatisation may sometimes be found scattered through the unexpanded 
lungs of infants born dead, and the mediastinal glands may also be enlarged 
and infiltrated m a similar way. The gummata are most often seen on the 
surface ot the lung ami are apt to soften 




ig. 85.— Congenital Syphilis. Disease of bones 
of upper and lower extremities 



the centre (Parrot). 



l'he liver 
F F 



434 



Syphilis 



of newly born infants may contain gummata : these may be of variable size, 
perhaps in some cases as large as a shilling on the surface, perhaps softening 
in the centre ; on section a diffuse infiltration may be seen. (See page 177). 

The spleen is frequently enlarged and indurated, especially where cachexia 
is a marked symptom, as pointed out many years ago by Gee. It is generally 
simply indurated, but miliary gummata have been found. 

Syphilitic disease of the bones may occur both early and late in the dis- 
ease. Caries of the nasal bones may follow the coryza, leading to the falling' 
in of the nose which is so common in syphilitic children ; or the bones may 
be completely destroyed. Caries of the hard palate and turbinated bones, 
as well as of the long bones, more especially the tibia, may occur. In the 
latter bone caries may follow periosteal nodes ; or thickening of the bones 
may be met with. Apart from caries a peculiar inflammation termed 





Fig. 86.— Swelling of lower ends of Tibia and Fibula, and also Radius and Ulna, from a 
syphilitic infant of four months old. The swelling lies at and above the line of junction 
between the epiphyses and shafts. (Compare with Rickety Enlargement, p. 398.) 



syphilitic epiphysitis is apt to occur near the epiphyses in the long bones, 
especially at the lower ends of the humerus, femur, radius, and tibia in infants 
who are suffering severely from hereditary syphilis. The mother notices that 
the infant does not move an arm or leg so freely as the other, and it screams 
as if in acute pain if the limb is handled or moved suddenly. An examina- 
tion of the end of the humerus, if the arm is affected, may show it to be swollen 
and tender, and the limb hangs useless, so that the term ' pseudo-paralysis ' 
has been applied. (See fig. 86.) The epiphyses of several of the long bones 
perhaps show an enlargement where they join the shafts of the bones, and 
sometimes a slight effusion is present in the joint. More rarely the pha- 
langes of the fingers are also swollen. The nature of this lesion has been 
studied with great care by Wegner, Parrot, Taylor, and Kassowitz. Separa- 
tion of the epiphysis from the shaft and the formation of an abscess may take 
place, though in this country the latter accident is rare. Lesions in the 



Hereditary Syphilis 435 

cranial bones have been described by Wegner and Parrot ; the former has 
found gummatous periostitis of the dura mater beneath the parietal bone, a 
possibility to be borne in mind when epileptiform attacks occur in syphilitic 
children ; the latter has laid stress on the cranio-tabes found in syphilitic 
children and also on the overgrowth of bone, forming bosses or osteophytes, 
on the surface of the frontal and parietal bones. To what extent either of 
these lesions is directly due to the syphilitic poison is uncertain ; certainly 
cranio-tabes occurs in association with rickets, and is also seen in wasted 
infants in whom evidence of syphilis is wanting. ( Vide chapter on DISEASES 
of Bones.) 

The osteophytic growths have been noted both in infants and older chil- 
dren ; they consist of small rounded elevations of bone \ inch to 1 inch in dia- 
meter, most commonly situated near the longitudinal or fronto-parietal sutures, 
and can be felt by passing the hand over the infant's scalp. In some cases 
there is an excessive formation of bone at the frontal and parietal eminences, 
with furrows or depressions along the sagittal and fronto-parietal sutures, 
thus making a cross, as it were, on the vertex : the skull is then said to be 
natiform. This condition also occurs in rickets. 

The teeth of the second or permanent set are often misshapen and 
peculiar. The most characteristic changes are seen in the central incisors 
of the upper jaw ; they are more or less dwarfed, peg-shaped — i.e. they taper 
inferiorly — slant towards each other, and have a central notch in their cutting 
edge ; the other incisors may be more or less dwarfed and notched. 

Affections of the eyes are most common about puberty, the commonest 
being interstitial keratitis, iritis, and choroiditis. The two former usually 
occur together, though they may occur singly. The first symptom noticed 
is watering and irritation of the corneal conjunctiva, then a steamy appear- 
ance or cloudiness of a portion of the cornea : this is followed by the forma- 
tion of minute blood-vessels on the surface of the cornea, giving the steamy 
patches in some cases a reddish or salmon-coloured tinge. These patches 
join the sclerotic, are generally symmetrical, and are apt to relapse. Dis- 
seminated choroiditis may occur : in such cases small patches of atrophy of 
the choroid, of a white or grey colour, are generally seen scattered about 
the fundus of both eyes ; pigmentation is frequently present ; there is often 
the remains of a past retinitis and neuritis. 

Ears. — Gradually increasing deafness, which is often very intractable to 
treatment and depends on labyrinthine mischief, is common in congenital 
syphilis. It usually appears at about the same age as interstitial keratitis, 
i.e. from the seventh to the fifteenth year, but occasionally begins much 
later. Complete deafness frequently results from this affection. The three 
lesions of the teeth, the cornea, and the ear are known sometimes as 
' Hutchinson's triad' of symptoms, and may be looked upon as quite patho- 
gnomonic. Middle ear disease is also sometimes caused by congenital s\ philis. 

Brain. — Gummata are rare in the brains of children : the) have been 
observed by Henoch in a child two years of age on the surface of both cere- 
brum and cerebellum, and T. Barlow has described multiple syphilomas at 
the base of the brain, with thickening o\~ the arteries. Chronic meningo- 
encephalitis, giving rise to idiocy, may occur, as may also chronic hydro- 
cephalus (see pp. 452 and 453). 

f f a 



436 Sy pi litis 

Diagnosis. — This is often difficult and sometimes remains uncertain. In 
the infant care must be taken not to mistake, as students are very apt to do, 
an erythema about the genitals, which has its origin in the irritation caused by 
fouled napkins, for a specific rash, or, on the other hand, hastily to assume 
that an infant is ?iot syphilitic because there is a certain amount of excoria- 
tion and rawness about the anus caused by the fretting of the wet napkins. 
No rash can be taken as characteristic which is not present in other places 
as well as about the genitals, out of reach of the irritating effect of the 
urine or fasces. Coryza in an infant a few weeks old is exceedingly suspicious, 
especially in the absence of signs of catarrh of the bronchial tubes or larynx, 
and if it remains chronic is probably syphilitic, even though a rash may never 
be present. Tenderness and swelling of the epiphyses of the long bones 
in an infant are strong evidences of syphilis ; we attach no importance to 
cranio-tabes, or bosses on the cranial bones, or the natiform skull, as they 
may be undoubtedly present in rickets and perhaps other conditions. 
Syphilitic epiphysitis can hardly be mistaken for the enlargement of the 
epiphyses present in rickets. In syphilis the swelling is situated between 
the epiphysial line and the shaft (see fig. 86), while in rickets the swelling 
involves the epiphysis itself (see fig. 66). Syphilitic thickening occurs in 
infants of six weeks to three months old, while the rickety enlargement is 
rarely seen before six months of age, and more commonly at a year or 
eighteen months of age. 

Treatment. — In all cases where the parents are known to have suffered 
from syphilis, or some older child has been affected, antisyphilitic treatment 
must be commenced without waiting for the development of symptoms, in 
the hopes of mitigating the disease or of preventing its development. The 
anti- syphilitic treatment of the parents who have had syphilitic children forms 
an important part of prophylactic management, and may prevent the taint 
from being transmitted from the mother to the foetus. In the treatment of 
infantile syphilis it should be borne in mind that the effects of the poison 
are apt to impair the functions of almost every organ in the body, and in the 
worse cases there is a marked tendency in the direction of anaemia and 
gastro-intestinal atrophy. The dietetics of the syphilitic infant require the 
most careful attention, especially if it has to be artificially fed, as such 
infants are exceedingly likely to suffer from aggravated dyspepsia and 
mal-nutrition. It should, if possible, be suckled by its mother ; if this is 
impossible it must be artificially fed, as a wet-nurse is not permissible on 
account of the danger of her becoming inoculated by the nasal or other 
discharges from the infant. As soon as the diagnosis is made or the disease 
suspected, mercury must be given in some form or other. The usual plan 
is to give mercury and chalk-powder in half-grain doses twice a day, this 
form of mercury being used on account of its mildness and its being less 
likely to disturb the bowels than calomel. If any looseness of the bowels 
follows its administration, it may be combined with a grain of chalk and 
opium powder or the compound cinnamon powder. In a few weeks the dose 
may be increased from half a grain to a grain : this treatment should be con- 
tinued as long as any of the special symptoms are present, or for some six 
weeks or two months, when the mercury maybe omitted for a fortnight or so, 
and the syrup of iodide of iron in five to ten drop doses may be substituted. 



Hereditary Syphilis 437 

If there is much cachexia or mal-nutrition, a few drops of cod liver oil may- 
be added. Instead of the mercury and chalk some prefer to give calomel 
in One-sixth to one-half grain doses combined with half a grain of saccharated 
carbonate of iron. In Vienna a combination of mercury and tannic acid is 
used (hydrarg. tannicum oxydulatum) when other mercury salts disturb the 
bowels ; the dose is the same as calomel. In obstinate cases, especially 
where the skin eruptions are chronic, sublimate baths as recommended by 
Baginsky may be used with good effect. A bath may be taken daily in which 
ten grains of corrosive sublimate are dissolved ; the child should remain in 
the bath some five minutes, care being taken that none of the water gets into 
its mouth. The baths are more cleanly than and preferable to the inunction 
of blue ointment, and act with greater certainty. During the time the infant 
is taking mercury the gums should be carefully watched, and any signs of 
stomatitis or sponginess about them should be the signal for at once dis- 
continuing all forms of mercury. It is, however, very rare for salivation to 
occur in children. The coryza should be treated, when the obstruction 
or secretion is excessive, by injections of weak solutions of nitrate of silver 
(gr. i ad §i) or boracic acid ; the dried secretion should be removed, and 
any soreness and excoriation about the nares or lips should be smeared 
with yellow oxide of mercury ointment, which may be applied on a small 
camel's hair brush. Boracic acid may be applied locally as a dusting powder 
to the rash about the genitals or elsewhere. During the relapses mercury 
should be given in some form or other, and the mucous patches and con- 
dylomata which so frequently accompany relapsed syphilis should be fre- 
quently dusted with finely powdered calomel. In the latter stages, during the 
tertiary symptoms the solution of bichloride of mercury in doses of half a 
drachm to a drachm, combined with iodide of potassium, should be given 
and continued for many months, when the syrup of iodide of iron may be 
substituted. Tertiary syphilis is apt to be very chronic, the ulcerations of 
skin and caries of bone and corneal affections remaining for months nearly 
stationary, and, quickly relapsing when treatment is suspended. Iodoform 
and the yellow oxide of mercury ointments are the most useful local appli- 
cations for the skin and conjunctiva, while a solution of nitrate of silver 
(gr. x ad 5 i) may be used as an application to the specific ulcerations of 
the mouth and palate. During the treatment of syphilis, both in infancy and 
later childhood, the most generous diet which can be digested must be pre- 
scribed. Abundance of fresh air and change must be insisted on, and the 
most scrupulous care taken to promote cleanliness and to prevent any non- 
syphilitic individual from becoming infected by any discharges from the 
patient. 

The mercurial treatment should be resumed after a fortnight's or three 
weeks' interval, even if all the symptoms have disappeared, and it should be 
continued for at least six months. 

In some cases of late congenital syphilis healing of ulcers or bone 
lesions will only be procured by the use of very large closes ot iodide oi 
potassium, either alone, or, better still, in combination with mercury. Wc 
have had to order twenty-grain doses of the iodide three times daily for a 
boy of about twelve before any material improvement was effected. 



43 8 Diseases of the Nervous System 



CHAPTER XX 

DISEASES OF THE NERVOUS SYSTEM 

Introduction. — The student who has gained his knowledge of the 
diseases of the nervous system entirely among adults, will be certain to find, 
when he comes to see the same class of diseases among children, that the 
difficulties of diagnosis are much greater in the latter, and that some diseases 
which are rarely met with among adults are common enough among children. 
This is no doubt true of disease in children generally, but it is especially 
true of the nervous system. For instance, he will find very early in his 
career that it is often exceedingly difficult to estimate the amount of pain 
from which a child or infant suffers. An infant or peevish child will cry 
from fear, discomfort, or bad temper just as loudly as from the severest pain, 
and it may be quite impossible to localise the seat of pain or, indeed, to find 
out what it is crying for. There may be a general hyperesthesia present, 
but it will be mostly very unsafe to draw any conclusions from this symptom 
alone as to the presence of organic disease, though it may be borne in mind 
that hyperesthesia is frequently present in the early stages of meningitis. 
The infant's legs may hang down helplessly, and he may at first think that 
they are paralysed, but a closer examination may disclose the fact that there 
is some epiphysitis or periosteal tenderness which has prevented the child 
from using the limbs. On account of the readiness with which reflex dis- 
turbances are evoked in the young, we often find ourselves in difficulties and 
in error. Thus the infant has one-sided convulsions ; are these due to a 
serious lesion on the opposite side of the brain, or to an intestinal catarrh or 
colic ? How often the differential diagnosis between gastric and cerebral 
vomiting in infants is difficult and for a time impossible ! The nervous 
system of the young is easily upset by a high fever or a poisoned condition of 
blood, and there may be drowsiness, retraction of the head, and convulsions 
• — symptoms which naturally suggest cerebral diseases such a meningitis. 

Among the diseases which are much commoner in the young than in the 
old, meningitis stands pre-eminent, and assumes in consequence a position 
of great importance. It occurs alike in apparently healthy and robust 
infants and children, and in those whose history and symptoms suggest 
tuberculosis in some of its phases. Cerebral haemorrhage from a ruptured 
artery is rare in the young, but an extensive bleeding may take place on 
the surface of the brain from over-distended veins or capillaries, and give 
rise perhaps to a lifelong hemiplegia. Convulsive disorders — the spasms 
being local or general — are vastly more frequent during the first two or three 
years of life than at any other period, and their results much more serious. 



Cerebral Congestion 439 

The infant may die in a convulsion from spasm of the glottis, or a meningeal 
haemorrhage may take place, and a serious injury to the brain may be thus 
caused. Among other diseases which are of greater frequency in early than 
in later life, acute atrophic paralysis and chorea may be mentioned. 

Clinical Examination. — The shape and size of the skull are of impor- 
tance as giving some indication of the size and configuration of the brain. 
The condition of the skull may be investigated by inspection, palpation, and 
mensuration ; neither auscultation nor percussion yields any indications of 
much practical importance. By inspection a general idea may be obtained 
■of the shape of the head, whether large (macrocephalic), small (micro- 
cephalic), asymmetrical, long (dolichocephalic), as in the negro, round 
(brachycephalic), as in the Mongols, hydrocephalic, or square, as in rickets. 
By means of palpation the condition of the fontanelles can be ascertained, 
whether bulging, as in hydrocephalus ; or depressed, as in anaemia ; or widely 
•open for the child's age, as in rickets. The edges of the bones may be felt 
to ascertain if they are thickened ; the parietal or frontal eminences may be 
unduly prominent, or various bosses may be present, as pointed out by 
Parrot. Undue thinness of the skull, more especially of the occipital, may 
be detected by firm pressure with the fingers, the bone being felt to bend or 
yield beneath the fingers. By means of mensuration, using calipers and a 
thin flexible piece of lead wire, a tracing of the outline of the skull, both 
longitudinally and transversely, may be made, and a graphic record, thus 
made, kept. In this way the frontal or occipital regions may be shown to 
be smaller than normal, or one parietal region may be flatter than the other, 
as in some cases of deficient development or injury at birth. 

The clinical examination will necessarily include observations on the 
condition of the muscles to see if any paresis or paralysis is present. A 
slight squint is easily overlooked, and the friends may have to be appealed 
to for their observations, as the squint may be present at one time and 
absent at another. The condition of the pupils must be observed, and it 
may be necessary to examine the optic discs and to test the refraction of 
the eyes. If there is any question of paralysis, the child should be examined 
when naked, and if it can walk, the character of its gait observed. The 
condition of the reflexes, especially the knee-reflex, and the presence or 
absence of ankle-clonus observed. An exaggerated knee-reflex with ankle- 
clonus is usually present in old cases of ' birth paralysis,' and in pressure 
myelitis when the disease is situated above the lumbar enlargement. But 
these phenomena are certainly also present in some cases of hysterical 
paraplegia, especially when the paresis has lasted some time. We have 
twice seen exaggerated knee-reflex, both times in boys, following an ill- 
defined feverishness, lasting several weeks, and finally ending by completely 
disappearing. The absence of knee-reflex suggests peripheral neuritis. 

Ankle-clonus is often also seen in old standing disease of the tibia when 
the leg has been in splints. 

Cerebral Congestion. — A passive congestion of the venous System 
inside the skull takes place whenever respiration ceases or is impeded, in 
consequence of an over-filling and distention o\ the right side of the heart. 
This is markedly so during a convulsion ami in acute general bronchitis. 
Does an acute active congestion take place without passing on into an acute 



44° Diseases of the Nervous System 

meningitis ? This question is difficult to answer. Certainly cases occur 
which suggest this. Thus we have seen school children, both boys and 
girls, who have been working hard at examinations, suffer from headache, 
vomiting, prostration, rigidity of the muscles of the neck, squint — symptoms 
which suggest cerebral irritation or an early stage of meningitis — recover 
entirely, after a few days' rest in bed, under the influence of bromides. We 
must not, however, forget that any symptoms of cerebral irritation in the 
young are extremely suggestive of a miliary tuberculosis of the arteries 
of the brain, which may be followed at any time by the symptoms of 
meningitis. 

Meningitis 

Tubercular Meningitis. — In tubercular meningitis there is an inflam- 
mation of the pia mater, set up by the presence of tubercles on the vessels,, 
more especially at the base of the brain. While tubercles and meningitis 
are very commonly found associated together post mortem, it must be borne 
in mind that a simple or non-tubercular meningitis is not uncommon, and also 
that tubercles may be present on the vessels without any meningitis, though 
the probabilities are great that if tubercles are present they will sooner or 
later light up inflammation of the meninges. Another point must also be 
remembered : that a meningitis so called is in reality a meningo-encephalitis ; 
the vessels which penetrate the grey matter of the convolutions are certain 
to join in the inflammation. 

Tubercular meningitis is less common in children under the age of one 
year than in older children ; simple or purulent meningitis is perhaps rela- 
tively more common at this period, though the tubercular form certainly 
does occur, but on account of the difficulty of distinguishing between simple 
and tubercular meningitis in infants and young children we are rarely justi- 
fied in making a differential diagnosis in the absence of a post-mortem. 
Between the age of one year and the commencement of puberty tubercular 
meningitis is a common disease. 

It rarely happens that the pia mater is the first part of the body to be- 
come the seat of tubercle ; a tubercular meningitis is in the large majority 
of cases preceded or at least accompanied by grey granulations or caseating 
tubercle in some other part of the body. A tubercular meningitis is often 
the closing act of a general tubercular process ; it may occur early or late, 
and, when once established, quickly brings the end. The post-mortem evi- 
dence of this is clear and decisive, for in the bodies of those dying with 
tubercular meningitis grey granulations or caseating tubercle will almost 
certainly be found in the lungs, bronchial glands, brain, spleen, or other 
organs. Clinically the same thing is also evident : children suffering from 
hip-joint disease, spinal canes, caseating cervical glands, or chronic tuber- 
cular peritonitis, are not infrequently cut off by an intercurrent attack of 
tubercular meningitis, or the latter follows whooping cough, measles, or 
pneumonia. In the large majority of cases there is a definite history of ill- 
health before the actual brain symptoms supervene. An exception to this 
is, however, seen in the case of infants and children under two years of age, 
in whom occasionally the attacks are sudden, supervening in the midst of 
apparent health. 



Tubercular Meningitis 441 

What determines the growth of tubercle on the pia mater and the subse- 
quent meningitis? No certain answer can be given to this question. It is 
easy, and perhaps natural enough, to attribute it to over-excitement of the 
brain, or excessive brain work ; and possibly this may be so in some cases 
in tubercular children, who have been badly fed and subjected to unfavour- 
able life-conditions, while their brains are being driven at the highest pressure ; 
but such cases must be exceptional. It must be borne in mind that tuber- 
cular meningitis attacks children a few months old and children in hospital,, 
and under conditions in which it is impossible that over-brain work can have 
had anything to do with the supervention of the meningitis. We cannot say 
why the tubercular process should in one case attack the brain and in other 
cases the peritoneum, pleura, or lungs. 

Symptoms and Course. Premonitory. — The onset is insidious and the 
early symptoms are ill-defined, being those of general malaise rather than 
of actual disease. In most cases there is a history of ill-health for several 
months, perhaps succeeding an attack of measles or whooping cough, during 
which time the child has wasted or lost flesh and become flabby. There 
may have been cough, dyspepsia, constipation, loss of appetite, otitis, en- 
largement of glands, or more or less feverishness, especially at night ; such 
symptoms are not in any way distinctive, and are often the result of a chronic 
intestinal or gastric catarrh : yet, if there is a family history which suggests 
tubercle, they necessarily excite suspicion. In some cases definite brain 
symptoms precede by many weeks the actual attack of meningitis, and 
then perhaps pass away or remit for a while. Among these may be men- 
tioned headache, squint, a staggering gait, an unusual tendency to fall, a 
temporary loss of control over the sphincters. The late Dr. Oxley records a 
case in which the boy's disposition entirely changed, and he showed a constant 
tendency to bite on the least provocation ; often there is extreme irritability, 
which is all the more suspicious if it occurs in a good-tempered child. Such 
symptoms are possibly due to the irritation caused by the presence of tubercle 
on the vessels or in the brain, which may perhaps precede for some time the 
attack of meningitis ; or it is quite conceivable that a temporary congestion 
or even a patch of meningitis may be present. 

It is impossible during the premonitory stage to do more than suspect 
the onset of tubercular meningitis or tuberculosis in some form or other ; in 
a large number of such suspected cases recovery gradually takes place with- 
out any definite diagnosis having been arrived at ; in these cases, however, 
we are hardly ever warranted in assuming that our treatment has been the 
means of warding offan attack, and we may be left in ignorance as to its nature. 
In some cases, especially in infants, there are no preliminary symptoms : the 
infant, while in apparent health, begins to vomit and gradually becomes 
comatose, or almost the first symptom which attracts attention may be a 
hemiplegia. In such cases a simple meningitis is perhaps suspected, but the 
post-mortem usually shows it to be tubercular. 

The premonitory symptoms gradually pass into the first oi the three 
stages into which the attacks are usually divided namely, the stage ofei 
ment. At the commencement of this stage the symptoms may be chiefly 
gastric, or they may be definitely cerebral from the first. In the former 
case the most prominent, and indeed sometimes for several days the only 



44 2 Diseases of the Nervous System 

symptom, is vomiting. This may begin after a meal and be attributed to 
some improper food, but it continues in spite of the most careful dieting, is 
usually accompanied by a clean tongue, and, while aggravated by food, often 
recurs, with much retching and nausea, when the stomach is empty. Too 
much stress must not be laid on the character of the vomiting, and perhaps 
for a few days a doubt may be entertained as to its true nature, whether due 
to cerebral disease or gastric irritation. The vomiting of meningitis is usually 
erratic, coming and going without any apparent cause. At this stage the 
child may be perfectly intelligent, and no direct cerebral symptoms may be 
present. Constipation is usually present : the abdomen, which is at first 
rounded, becomes flabby, and later retracted, from the contraction of the 
intestinal walls which takes place. Before long other symptoms, more 
directly pointing to the head, become developed. There are headache, giddi- 
ness, great irritability, intolerance of light and noise. The child likes to be 
nursed by its mother, lies on her lap, and resists the interference of others. 
Its temper has completely changed : it is feverish and extremely irritable. 

The symptoms may be more definitely cerebral from the first, and the 
vomiting may not be a prominent symptom. The child complains of head- 
ache, which is often intense ; there is giddiness and staggering gait ; its 
sleep is disturbed by dreams, or it wakes up with a shrill cry of distress, 
often of a piercing character, and known as the ' hydrocephalic cry.' The 
child neglects its toys, preferring to lie quiet and undisturbed. The pulse is 
usually quickened, the temperature raised a degree or two at night, and the 
tongue becomes coated with fur. which has often a brown or yellowish tinge. 
Remissions are apt to occur, and for a while perhaps the little patient is 
again himself, bright and chatty, and ready for his toys, but to the dis- 
appointment of the friends the old symptoms return with greater intensity. 
So far the symptoms have been those of cerebral excitement, caused in all 
probability by the inflammatory congestion of the pia mater which is present : 
following this, comes the stage in which effusion is taking place and the 
brain functions become more and more effaced. 

The second stage, often called the stage of transition, is marked by the 
commencement of drowsiness. The child becomes more and more dull and 
heavy ; it is no longer found on its mothers lap, but in bed. in a half-drowsy 
state. It likes to lie quiet, does not wish to be disturbed, and if roused it 
answers in a snappish manner and then curls up again and is off to sleep. 
The vomiting now is usually less urgent or perhaps ceases ; the abdomen is 
retracted, the bowels confined. The pulse is usually slower than in the 
earlier stages, and is frequently irregular and hesitating. Commencing optic 
neuritis may be observed, but the child in this stage will often keep its 
eyes spasmodically closed, so that observations on the discs are rendered 
difficult. The edges of both discs appear blurred and indistinct, from the 
presence of swelling ; the veins become distended and tortuous, but the 
changes are never so marked as they are when a cerebral tumour is present. 
The intensely congested and swollen discs, with various minute haemorrhages 
so often seen in other forms of cerebral disease, never occur, possibly because 
there is not sufficient time for these extreme changes to develop. Miliary 
tubercles may be present in the choroid, but these — as far, at least, as our 
experience goes — are only present in cases of general miliary tuberculosis. 



Tubercular Meningitis 443 

Various other phenomena are apt to supervene, such as convulsions, muscular 
twitchings, paralyses, and spastic contraction of the muscles of the neck and 
back, less often of the limbs. The convulsions may be general and bring 
about a fatal result, especially in young children. The paralyses may involve 
the muscles of the eye, face, or limbs of one side. Retraction of the head 
is very common : it is sometimes so extreme that the back of the head comes 
in contact with the spine ; the back is frequently arched. There is often a 
spasmodic contraction of the masseters, so that the child grinds its teeth, 
making a peculiar and unpleasant grating sound. There is apt to be incon- 
tinence of the urine and faeces. As the child becomes more and more 
drowsy the respirations become altered in character, approaching the 
' Cheyne-Stokes ' type — i.e. the respiratory movements become shallower and 
shorter, until they cease ; then a distinct pause in the respirations takes place, 
to be followed by a deep, sighing inspiration, which is again followed by a 
series of shallow respiratory movements, or the pause is followed first by 
shallow then by deeper respirations, as in fig. 87. 

From a condition of drowsiness the child passes into the third stage, or 
stage of coma. It can no longer be roused or recognise its friends ; the con- 
junctivae become insensible, the pupils dilated and sluggish, and now the 




Fig. 87. — Tracing of Movements of Chest Walls from a case of Meningitis, showing 
' Cheyne-Stokes ' respiration. (After Landois and Stirling.) 

optic discs can be examined without difficulty. The muscles of the limbs 
and abdomen are now weak, flabby, and toneless. The tongue is now coated 
with a thick brown fur, and sordes appear on the teeth and black crusts on 
the lips. The skin is harsh and dry, and the wasting becomes extreme. 
Excessive secretion takes place from the conjunctivae, so that the eyes 
become smeared with mucus or pus. The pulse becomes weak and rapid. 
The coma is usually profound, so that the child cannot be roused even for .1 
moment, but usually the power of swallowing is retained to the last. In this 
miserable condition the patient lasts for many days, perhaps a week, and 
even after it appears moribund slight improvement may take place. The 
total duration of the disease is usually about three weeks, but, especially in 
young children, death may take place much sooner. 

The temperature throughout the course is most uncertain, but always of 
an irregular, intermittent type, sometimes varying three or four degrees during 
the twenty-four hours ; at other times the flights are much less marked. The 
temperature is of course modified if there is an extensive tubercular process 
in progress in the lungs and other parts. Hyperpyrexia is not uncommon ; in 
one case that of a boy of three years of age, who was convulsed, the temperature 



444 Diseases of the Nervous System 

rose to io8° F. (rectal temperature) shortly before death. The post-mortem 
showed tubercular meningitis, caseous mediastinal glands and some miliary 
tubercles in the spleen and kidneys. The lungs were free. The paralyses 
which are apt to occur are seldom marked, often only temporary, being rather 
paresis than paralysis ; sometimes, however, when extensive softening takes 
place in one hemisphere from thrombosis of some large vessel, the paralysis 
of an arm, or arm and leg, may be complete. Anaesthesia is rarely, if ever, 
present ; hyperesthesia is not uncommon in the early stages, but more as a 
part of a general irritability than anything else. 

Whilst in typical attacks the various stages are fairly well marked, cases 
are frequently met with which are extremely irregular, where the typical 
symptoms are absent, and no diagnosis is made until the child is comatose 
and moribund. In such cases the symptoms may be indefinite for a week 
or two, then a marked improvement takes place, which gives hopes that our 
diagnosis of meningitis is incorrect, when suddenly convulsions and coma 
supervene and death speedily occurs. The fact that a remission of many 
of the symptoms may take place, the child being decidedly improved for 
a while, must be constantly borne in mind. In other cases the course is 
short and sharp, in this respect resembling some cases of simple meningitis. 
Thus, for instance, a boy of eight years, who came of a tubercular family, 
attended at school till April 23, though for the last few days he had not felt 
well. He then stayed at home on account of cough and weakness ; he began 
to vomit on May 3 ; the next day he became drowsy, gradually passing into 
coma, and died on May 8. At the post-mortem miliary tubercles, with 
some pneumonia, were present in the lungs and in the abdominal organs ; 
there was also tubercular meningitis, with much fluid in the lateral ventricles 
and subarachnoid space. 

In infants of six months and under the symptoms are often the reverse 
of characteristic ; the infant perhaps vomits food, but in other ways appears 
quite well, and the vomiting is not unnaturally looked upon as due to some 
gastric irritation ; then perhaps some rigidity about the muscles of the neck 
and slight retraction of the head are noticed, and the infant gradually passes 
into a condition of drowsiness and coma. Muscular twitchings of the facial 
muscles or frequent clonic spasms of the muscles of a limb or arm may be 
present. In other cases the infant appears to be 'teething/ there is some 
slight fever and restlessness, but nothing to indicate cerebral disturbance ; 
then suddenly convulsions come on, followed by paralysis of an arm and leg, 
and perhaps coma. The state of the fontanelle is often a help in diagnosis 
in doubtful cases, as is also the rigidity of the muscles of the' neck and con- 
sequent retraction of the head. The fontanelle is full and bulging, and in 
the later stages the veins on the forehead may be more prominent than usual,, 
and the head may actually enlarge from the presence of an excess of fluid 
in the lateral ventricles. The retraction of the head is not diagnostic, it 
occurs in cases of chronic meningitis, and sometimes it appears to be the result 
of reflex irritation from the pulmonary and abdominal viscera. Hutton has 
noted it in a case of commencing pneumonia in an infant. It occurs also in 
otitis. 

Simple Meningitis. — Simple meningitis is not so common a disease as 
tubercular, though it doubtless is more common than is usually thought, as 



Simple Meningitis 445 

there is little doubt that it is often mistaken for the tubercular variety ; indeed, 
it may be quite impossible to distinguish one from the other during- life. It 
is perhaps most common during the first and second year, though it is by 
no means confined to these periods. It may be idiopathic, arising without 
any discoverable cause ; there is, however, often a history of a fall or blow 
on the head, and it is also apt to supervene during an attack of pneumonia, 
pyaemia, or typhoid fever, or to arise from an otitis, or from carious bone in 
other positions. It appears to occur in hot whether, especially after exposure 
to the sun. It is said also to occur in the course of rheumatism and 
erysipelas. We have once seen it in scarlet fever, death taking place on the 
twenty-first day, but unfortunately there was no post-mortem, and, as the 
girl had also had discharge from both ears, it was possibly due to an extension 
of the inflammation from the tympanum to the membranes of the brain. It 
occurs both sporadically and also in epidemics, in connection with menin- 
gitis of the cord or cerebro-spinal meningitis. Syphilis is a cause of menin- 
gitis, but this is rarely acute ; it gives rise to a chronic basal meningitis, or 
a local meningitis in the neighbourhood of a gumma. 

Symptoms. — It is unnecessary to discuss the symptoms of simple menin- 
gitis in detail, inasmuch as they closely resemble those of the tubercular 
variety ; it will be more useful to point out the typical forms in which menin- 
gitis occurs. 

Acute Form. — In some cases, both in infants and older children, the 
attack may run a very acute course, death from convulsions taking place in 
two or three days. The acute meningitis in some of these cases is asso- 
ciated with a pleuro-pneumonia or peritonitis. As an instance of rapid 
death from what was probably an acute meningitis, though the post-mortem 
examination showed no effused lymph, the following case may be taken as 
an example : 

Acute Meningitis. — Beatrice B. , aged 5^ years, was a healthy child till six months ago, 
when she was taken with pain in the head, fever, and vomiting, but recovered in a day or 
two. Two days before admission, when playing in the street, she ran in, complaining of 
pain in the head, and vomited ; she continued to vomit constantly for two days ; she had 
a fit shortly before admission. There had been no injury to the head ; the weather was 
hot at the time (August). On admission she looked ill, her face having an expression of 
anxiety : two hours after admission she was convulsed and died. Her temperature was 
not taken. At the post-mortem all the organs were healthy, the capillaries of the brain 
were intensely injected, and there was much clear fluid in the lateral ventricles : the 
arachnoid membrane was somewhat opaque. 

In this case microscopical examination showed that the capillaries of the 
meninges and grey matter of the brain were distended and gorged with 
blood, and, though it cannot be certainly assumed that this congestion was 
primary and inflammatory, there is a strong probability that the ease was 
one of acute inflammatory congestion of the brain ami membranes. Similar 
cases of rapid death from acute hypersemia of the brain after exposure to a 
hot sun are recorded by Lewis Smith and Soltman. Henoch mentions a 
similar case in a girl of five years, the attack beginning in the same way 
with headache and vomiting, death taking place within forty eight hours. 
preceded by convulsions and cOma. At the post-mortem a purulent exuda- 
tion was present on the convexity and at the base o\ the brain. 



446 Diseases of the Nervous System 

In the following case meningitis supervened on acute diarrhoea : 

Acute Enteritis, Meningitis — Annie B. , aged 3I years, was seized with vomiting and 
purging (in August) ; the next day, when admitted, she was in semi-collapsed condition. 
A few hours afterwards she lapsed into unconsciousness. She was delirious, and there 
were muscular twitchings. Death took place rather suddenly at the end of the second day 
of the illness. At the post-mortem the pia mater was intensely congested, the arachnoid 
opaque, the Sylvian fissures were glued together with lymph, there were no tubercles; 
there were patches of congestion in the intestines and commencing pneumonia of the base 
of the right lung. 

These extremely acute cases are exceptional, and a doubt may often 
surround the diagnosis, as acute meningitis in the early stages may with 
difficulty be distinguished from the onset of some zymotic disease, as scarlet 
fever or typhus, or perhaps more likely of pneumonia ; and if the course 
terminates early in a convulsion it may be impossible even at the post- 
mortem to say with certainty what has been the exact nature of the case. 
Death from a convulsion, accompanied by spasm of the glottis, gives 
rise to a mechanical engorgement of both lungs and brain, and caution is 
required in positively asserting that an early meningitis or pneumonia is 
present. 

In the majority of cases acute meningitis runs a course of a week or ten. 
days, the symptoms resembling those described under tubercular meningitis. 
There may be a history of an injury, or of a past otitis, or of exposure to the 
sun, or positively of excessive brain-work. The early symptoms are those 
of intense headache, with injection of the conjunctiva?, vomiting, delirium, 
strabismus, and often high fever, perhaps as high as 103 to 105° Later, 
the pulse becomes slow and hesitating, the abdomen is retracted, the cer- 
vical muscles are rigid, and Cheyne-Stokes respiration, coma, and various 
paralyses ensue. At the post-mortem a more or less intense, perhaps puru- 
lent, meningitis is found affecting the convexity and base of the brain. 

Subacute Form. — In other cases the symptoms are less intense and the 
course longer. Infants are often the sufferers in these cases. The menin- 
gitis may be secondary, coming on in the course of other diseases, as, for 
instance, broncho-pneumonia ; instead of the infant improving, as was ex- 
pected, cerebral symptoms, such as vomiting, drowsiness, retraction of the 
abdomen, and cervical opisthotonos, make their appearance. The infant may 
remain for weeks in a semi-comatose condition, being able to swallow, and at 
times perhaps appearing sensible and recognising those about it ; it gradually 
wastes, the cervical opisthotonos becomes extreme, possibly the legs draw 
up, the head enlarges, bed-sores form, and the child dies convulsed. At 
the post-mortem the base of the brain, including the pons and cerebellum, 
is found glued to the bone by organising lymph, the lateral ventricles are in- 
tensely distended, the choroid plexus dilated and covered with lymph, and 
possibly the aqueduct of Sylvius is occluded. In such cases the possibility 
of the meningitis being due to syphilis must be borne in mind. 

The following case may be taken as an instance : 

Basal Meningitis, Hydrocephalus. — E. P., aged 7 months ; no history of syphilis. At 
6 weeks of age had an attack, during which he was always crying and throwing his head 
•back. A month ago he became drowsy and dull, and had twitchings of right arm and leg. 
He is unable to see. Admitted June 13. Constant vomiting ; abdomen retracted ; limbs- 



Cerebrospinal Meningitis 447 

rigid ; toes point ; fingers are flexed. From June 13 to June 25, when he died, he was 
comatose ; there was remarkable hyperpyrexia ; the temperature rising on succeeding 
days to 106 F. , 108 "6, 107, 107*4, and 107-8 before death. Post-mortem showed lymph 
mostly confined to the interpeduncular space, pons, and base of cerebellum. Both 
ventricles contained fluid and lymph ; cortex thinned to about \ inch in thickness from 
internal pressure. 

A subacute meningitis may occur in older children, and recovery from 
such attacks apparently takes place. Thus in a case of our own — that of a 
boy who died suddenly in apparent health, and on whom a coroner's inquest 
was held— an acute hydrocephalus was present, with some adhesions between 
the brain and the skull, apparently the remains of a meningitis from which 
there was a history of the boy having suffered some months before. 

As an example of a simple subacute meningitis following an injury, the 
following case of Dr. Hutton's may be referred to : 

Basal Meningitis, Hydrocephalus. — William C. , aged 8 years, fell into a cellar, striking 
the back of his head, some three months before admission. He vomited off and on for 
a day or two, but did not lie up ; he suffered from pain in the back of his head almost 
constantly after the fall. He was admitted with squint and pupils of unequal size ; he- 
had convulsions, optic neuritis, and lapsed into a semi-comatose state with Cheyne-Stokes 
respiration. He died twenty-four days after admission. At the post-mortem the dura 
mater was thickened and congested, there was much lymph at the base and between the 
hemispheres, and also between the latter and the cerebellum ; the lateral ventricles were 
much dilated and distended with serum. There were no tubercles anywhere. 

The following case illustrates the association of subacute meningitis and 
hydrocephalus with pneumonia : 

Basal Meningitis, Hydrocephalus, Chronic Pneumonia. — R. V. R. , aged 5 years, was 
always a healthy girl till seven weeks before admission, when she had an attack of feverish- 
ness and vomiting ; she has vomited more or less ever since ; she has also been losing 
flesh. On admission she was drowsy and irritable ; screaming when disturbed with a 
shrill cry ; the head was thrown back, the neck retracted ; there was no optic neuritis. A 
few days after she had two fits. She continued to vomit at frequent intervals. There was 
much rigidity of the muscles of the neck, with the head thrown back ; the hands and arms 
remained normal, while the hips and knees were flexed and the abdomen retracted. 
Later she suffered from double pneumonia at the bases, she wasted more and more, 
gradually became unconscious, and died ten or eleven weeks from the commencement of 
her illness. An examination of the brain showed that the Sylvian fissures were matted 
together with fibroid adhesions ; similar adhesions were present in interpeduncular space 
and surrounding the third and fourth nerves ; fibroid adhesions were also present on the 
upper surface of the cerebellum. The lateral ventricles were much dilated anil distended 
with fluid ; there had also been an inflammatory condition of their lining membrane, with 
exudation of fibrin. There was no tubercle anywhere; there was a double pneumonia 
becoming caseous. 

Cerebro-spinal Meningitis. — Cases in which an inflammation of the 
meninges of the cord is associated with meningitis occur both sporadically 
and in epidemics. Sporadic cases are not uncommon, especially in infants : 
epidemics are rare in this country, but limited outbreaks have occurred in 
Dublin and Glasgow. The symptoms of cerebro-spinal meningitis in infants 
closely resemble those of simple meningitis, but usually there is more marked 
rigidity of the cervical muscles ami muscles of the spine, the legs may be 
rigid and drawn up, and there may be more or less rigidity about the muscles 
of the arm and forearm. Sometimes there is opisthotonos resembling tetanus. 



.448 Diseases of the Nervous System 

In older children pain in the back and limbs may be complained of, being 
more especially referred to the back of the neck or sacrum : sharp shooting- 
pains may be complained of in the limbs. There may also be general 
hyperesthesia. In the epidemic form purpura and herpetic eruptions are 
common. Pneumonia is a common complication. The diagnosis between 
cerebral meningitis and a cerebro-spinal meningitis in infants is very difficult, 
often impossible, as it is difficult to localise pain and to arrive at a conclusion 
as regards a general hyperesthesia. Retraction of the head and more or 
less rigidity in the limbs may be present in both, but they are most marked 
when the spinal meninges are affected. Both tetanus and tetany may be 
mistaken for it : in the former there is marked trismus before the onset of 
the opisthotonos, and the temperature is normal or only slightly raised ; 
and in the latter the peculiar spasm of the muscles of the hands and feet, 
and normal temperature, suffice to distinguish the two diseases. 

latent Form.— Meningitis, like peritonitis and pleurisy, may be present 
without giving rise to any very definite cerebral symptoms ; this is especially 
so when it occurs secondarily, and the symptoms to which it gives rise may 
be overshadowed by the primary disease. It may occur in association with 
acute pneumonia or peritonitis, or acute intestinal catarrh, without its pre- 
sence being suspected, partly because the headache, delirium, and fever are 
naturally attributed to the more obvious disease present, and there is neces- 
sarily a difficulty in unravelling the complex association of symptoms and 
referring each to its cause. In some few instances a meningitis may exist 
without there being any cerebral symptoms whatever, as in the following 
case : 

Purulent Meningitis. — An emaciated child (boy) of 4 years of age, who had recently 
suffered from whooping cough, was admitted to hospital with some dullness at the base ot 
one lung. There was a history of diarrhoea, and during the fortnight preceding his death 
he had five or six diarrhceal stools daily. There was a hectic temperature, no vomiting, 
headache, or optic neuritis ; he was perfectly intelligent, and died apparently of exhaustion. 
It was supposed that there was general tuberculosis. At the post-mortem the lungs were 
found adherent to the diaphragm ; some inspissated pus was found present at the left 
base, evidently the remains of a small empyema ; there were no tubercles anywhere. 
There was some purulent lymph covering the inner surface of the dura mater, the convex 
surface of the brain, and the vessels in the transverse fissure, and bathing the surfaces of 
the lateral ventricles ; the base of the brain was matted with lymph. There was clear 
fluid in both tympanic cavities, but no pus. 

It is in wasted, anaemic children that such lesions as purulent menin- 
gitis, pleurisy, or peritonitis may exist without giving rise to marked 
symptoms. 

Prognosis. — As soon as a diagnosis of tubercular meningitis is made 
there is little hope of recover}-. In any case the hope must be rather that 
our diagnosis is wrong than that a permanent recover} 7 can take place from 
tubercular meningitis. Yet undoubtedly the meningitis produced by the pre- 
sence of tubercle does not always kill at once, and, moreover, in any case there 
is the hope that the meningitis is a simple one without the presence of tubercle. 
We have seen at least three cases — in which there was good evidence to show 
that they were suffering from tubercular meningitis — recover for a time and 
die subsequently of a second attack or of a general tuberculosis ; one of these 
cases may be shortly referred to. 



Diagnosis of Meningitis 449 

Tubercular Meningitis. Temporary Recovery. — Mary S. , aged 6% years, was quite 
well till a month or two before admission ( to hospital, when several 'cold abscesses' 
formed on her legs and discharged. Lately she has had headache, been giddy, staggered 
in her gait, and rambled at night. For several nights after admission she was restless, 
and screamed with pain shooting through her head ; an internal squint was noted in the 
left eye ; she was fairly sensible in the daytime, but complained of headache, and fre- 
quently passed her motions under her ; there was occasional vomiting. She was treated 
with ice to her head and complete rest in bed, and bromides. There was slight optic 
neuritis, which gradually subsided during her stay. She gradually improved, and was 
discharged after a three months' stay, apparently quite well. She was readmitted six 
months after with undoubted signs of meningitis, and died after a fortnight's illness. 
The. post-mortem showed miliary tubercles in the lungs, cheesy nodules in the liver, recent 
tubercles on the vessels at the base of the brain, and recent lymph ; there was also very 
distinct fibrous tissue at the base, as if resulting ' from a past inflammation ; the inter- 
peduncular space was matted, so that the third and fourth nerves had to be dissected out 
and cleaned of fibrous tissue, and the lobes along the Sylvian fissures were firmly matted 
together. The history of the case and the post-mortem appearance made it clear that a 
recovery had taken place from a basal meningitis in a tubercular subject. 

A permanent recovery from an attack of tubercular meningitis means in 
the vast majority of cases a recovery from a general tuberculosis — a result 
which is exceedingly improbable. 

The prognosis becomes bad in the extreme where the patient has sunk 
into a drowsy condition and Cheyne-Stokes respiration is present, though 
several days may elapse before the end comes. 

The prognosis in simple meningitis is certainly more hopeful, especially 
in the subacute or more chronic cases. In those with an acute onset, high 
fever, and delirium, but little hope can be entertained, while the subacute may 
recover with chronic hydrocephalus and rigidity of the lower limbs and de- 
fective intelligence. Nevertheless, cases which are looked upon as almost 
certainly fatal will occasionally recover. 

Diagnosis. — In a disease which begins so insidiously and assumes such 
varied forms the diagnosis is necessarily difficult. It must be in the 
experience of most to have made mistakes in diagnosis, in suspecting the 
onset of tubercular meningitis where the patient is only suffering from some 
dyspepsia or intestinal catarrh, and, on the other hand, making light of the 
anxieties of the friends when subsequent events have justified their fears. As 
regards diagnosis in the early stages too much stress must not be laid on 
irritability, grinding the teeth at night, loss of appetite, wasting, and sleepless- 
ness, as these may be symptoms of a perfectly recoverable disease. On the 
other hand, sickness, giddiness, frequent stumbling, staggering gai tempo- 
rary squint, loss of power of the sphincters, even though they remitted after 
a while, would justify grave suspicions. They may indicate the presence ot 
tubercle or some irritation of the brain, which may be quickly followed bv 
definite symptoms of meningitis. 

The principal errors which are likely to be made may be summed up as 
follows : 

i . Mistaking the vomiting of meningitis tor some form o( gastro- intestinal 
disturbance. 

This is a very common mistake in the early stages in eases oi meningitis, 
which begins with much vomiting. 

The vomiting of meningitis, like the vomiting of gastric catarrh, usually 



450 Diseases of the Nervous System 

follows the ingestion of food, but is more likely to follow any disturbance of 
the patient ; it may occur when the stomach is empty and the tongue clean. 
It is not very amenable to treatment, and is indifferent to the character of the 
food taken. The vomiting of a gastric disturbance mostly ceases after the 
stomach and bowels have been unloaded. In any case of causeless vomiting 
in a child a careful look-out must be kept for more definite brain symptoms, 
such as convulsions, dilated sluggish pupils, retracted head, and retracted 
abdomen. A hesitating or intermittent pulse would strongly suggest the 
onset of meningitis. The past history of the patient is often important. 
The vomiting and convulsions present at times during dentition may be a 
source of difficulty. 

2. The mistake may be made of attributing to meningitis cerebral sym- 
ptoms due to the presence of some febrile disorder or reflex irritation. A 
child cutting his teeth may be irritable, heavy, drowsy, may start in his sleep, 
and be feverish, simply from the effects of dentition or from undigested or 
improper food in his alimentary canal. The presence of fever of short stand- 
ing is against meningitis, as also is evidence of dyspepsia, such as flatulence 
and colic ; the condition of the gums should be carefully examined. A few 
days would decide the diagnosis. The diagnosis between typhoid and 
meningitis is not usually difficult, that between typhoid and acute miliary 
tuberculosis being often much more so. The symptoms presented by a child 
sickening for typhoid may not be unlike those presented in the early stages 
of meningitis ; vomiting, however, is not a symptom of typhoid : the fever 
present and the condition of the abdomen would usually decide the diagnosis. 
The possibility of a simple meningitis occurring in the course of typhoid or 
pneumonia must be borne in mind, though it is not a common complication 
in either case. 

3. At the end of certain exhausting diseases, such as acute diarrhoea, 
marasmus, &c, in infants, cerebral symptoms due to arterial anaemia of 
the vessels of the brain are apt to arise, such as convulsions, coma, con- 
tracted pupils, convergent squint, &c. This condition has been called 
' false hydrocephalus.' The history of the case, the depressed fontanelle, 
the almost pulseless condition of the infant, and the rapid onset and course 
of the ' false hydrocephalus,' would usually distinguish it from meningitis. 

The differential diagnosis between tubercular and non-tubercular menin- 
gitis is often impossible. A family history of tubercle or a history of the 
individual having suffered from caseous glands or other tubercular manifes- 
tations, or having recently suffered from whooping cough or measles, would 
naturally favour a diagnosis of the tubercular variety, as would also an 
insidious onset. On the other hand, the history of a blow, or an otitis, or 
exposure to a hot sun, and a stormy onset, would favour the diagnosis of 
the non-tubercular form. 

The diagnosis between acute meningitis and otitis is often difficult, and 
yet it is of the greatest importance. The relation between the two conditions 
is somewhat complex : a meningitis may undoubtedly arise from contiguity 
of diseased bone in the ear or acute suppurative otitis ; a purulent meningitis 
may exist with suppuration in both tympanic cavities or the latter cavities 
may contain cloudy fluid only, under circumstances which make it probable 
that the meningitis and otitis are both dependent on the same cause, and are 



Tubercular Meningitis 45 r 

not related as cause and effect. There is much reason to believe that an 
acute suppuration in the middle ear may closely simulate acute meningitis, 
and there is little doubt that they have often been mistaken one for the 
other. Cases which have been diagnosed as acute meningitis have quickly 
recovered after a discharge of pus from the ear, either bursting through the 
tympanic membrane spontaneously or being relieved by incision. In cases 
■of double suppurative otitis there may be intense pain in the head, fever, 
delirium, convulsions, optic neuritis, and deafness. The point of greatest 
diagnostic importance is the deafness without facial paralysis ; for, as Gowers 
points out, meningitis ' never gravely injures the auditory nerve without the 
adjacent facial nerves ;' nevertheless the diagnosis between otitis and otitis 
with superadded meningitis is exceedingly difficult and often impossible. 

Morbid Anatomy. — The bodies of those who have died of tubercular 
meningitis are usually wasted in a high degree, but in some acute cases they 
may be fairly nourished. On removing the skull-cap and exposing the 
convex surface of the brain the veins on the surface will be found to be 
unusually full of blood ; the convolutions are flattened, having been com- 
pressed by the distended lateral ventricles, and their surfaces are dry and 
sticky. More or less purulent-looking lymph is present : it may be usually seen 
on the lateral, less often on the convex surface. On examining the base, the 
effusion of lymph will be found to have taken place much more freely than 
on the convex or lateral surfaces. The Sylvian fissures will be seen to be 
matted with lymph ; the interpeduncular space, with the optic commissures 
and tracts, the third, fourth, and eighth nerves, and the inferior surface 
of the pons, and cerebellum, will be found in the same condition. Lymph 
may generally also be found around the medulla and spinal cord. An 
examination of the small arterial branches will show that they are studded 
with minute grey or yellowish tubercles ; the lumen of some may be 
occluded with thrombi. 

In some cases hardly any lymph will be found, but instead the arachnoid 
is opaque and there is more or less effusion of cloudy fluid beneath it, while 
the brain substance is cedematous and watery. 

Important changes are also present in the lateral ventricles. The vessels 
in the ventricles and great fissure forming the choroid plexuses and velum 
interpositum are studded with tubercles and besmeared with lymph : the 
lateral ventricles are distended with fluid, while in the majority of cases 
the parts around, the corpus callosum. fornix, and optic thalamus, have 
undergone white softening, and may be washed away or ragged out by a 
stream of water. The presence of fluid in excess in the lateral ventricles 
is due to the inflammatory processes going on in the choroid plexuses ; This 
gives rise when in excess to dilatation of the ventricles, softening of the sur- 
rounding parts, and flattening of the convolutions. It was these mechanical 
effects which so struck the older observers like Whytt, who overlooked the 
presence of tubercles as the primary cause, and saw only in such cases an 
'acute hydrocephalus' or 'water on the brain.' What further justifies these 
older observations is that in some cases the amount o\ lymph is very -mall 
and tubercles arc found with difficulty, while there is much subarachnoid 
fluid as well as distention o\ the ventricles, and the brain substanci 
and (edematous. In a few cases large tracts o\ the superficial or central 



45 2 Diseases of the Nervous System 

parts of the brain are softened and diffluent, the brain substance being 
yellow or plum-coloured from the presence of extravasated and altered blood, 
effects due to thrombosis or some disturbed condition of the circulation. 
A microscopical examination of hardened portions of the grey matter will 
show tubercles and effusion of leucocytes around the capillary arteries which 
enter the surface of the brain. 

How do the symptoms during life correspond with the appearances found 
after death ? The older writers were probably correct in ascribing the 
excitement during the first stage to the inflammatory engorgement of the 
arterial system of the brain ; the later stages of drowsiness and coma to the 
effusion of fluid into the lateral ventricles, which gradually compressed the 
surrounding parts and interfered with their blood supply ; the hemiplegia, 
paralysis of facial, &c, to the softening which so frequently takes place. The 
retraction of the head and stiffening of the limbs are also due, we are in- 
clined to think, to the pressure exerted on the motor tract by the ventricular 
effusion. 

Other tubercular lesions are constantly found in association with tuber- 
cular meningitis, the commonest of these being caseous mediastinal glands. 
The lungs also are rarely free from tubercle. 

In non-tubercular meningitis the distribution of the lymph, which is often 
purulent, is less exclusively basal, more often being found over the convex 
surface and between the hemispheres in the longitudinal fissure. In the 
more chronic cases the base of the brain and cerebellum may be adherent 
to the skull, and much fluid may be present in the lateral ventricles. 

Treatment. — The prophylactic treatment of tubercular meningitis is 
much the same as that of tuberculosis generally. All children who are so 
inclined require the most constant care in all the relations of life. Residence 
in cities must be prohibited, and country or seaside life insisted upon. A 
farmhouse where pure milk and cream &c. may be had, in a bracing but 
not too bleak situation, may be selected as a residence. All book work should 
be stopped, and all forms of excitement be strictly prohibited. The diet 
should be carefully regulated ; fats, if they are found to agree, should be 
taken in fair quantities. 

The child should be warmly clad and carefully protected from changes 
of weather. The bowels, if they are inclined to be constipated, should be 
carefully regulated with hyd. c. cret. or rhubarb and soda. The slightest 
suspicion of cerebral symptoms should be met by putting the child to bed 
in a darkened room, giving it a calomel purge, and an exclusively milk diet, 
and by the free administration of bromides. One or two grains of calomel 
with some sugar may be given, and some saline, such as a quarter or half 
a seidlitz-powder, the following morning. Five to ten grains of bromide of 
potassium should be given every four hours. The vomiting is best treated 
by purging smartly, and giving peptonised milk prepared with Benger's 
peptonising powders, or Savory and Moore's tinned peptonised milk. If 
persistent vomiting follows the giving of food, all food must be stopped 
by the mouth, and Brand's extract, or peptonised milk and bromide, must 
be given by means of an enema. Nothing is gained by continuing to 
purge after the initial dose of calomel has emptied the bowels thoroughly. 
If there is much cerebral excitement, larger doses of bromide may be given 



CJironic Meningitis 453 

with the tincture or succus hyoscyami. We doubt very much if blisters, 
setons, or leeches are of any service in tubercular meningitis, though in 
simple meningitis, if the excitement or delirium is severe, a leech applied to 
the temples will certainly relieve. Cold to the head is of undoubted value 
and in all cases should be applied, an ice-bag of india-rubber being used in 
preference to any other form. Letter's tubes form a convenient method of 
applying cold to the head, and they can be used where ice cannot be obtained. 
Mercury given freely in the form of perchloride is of all drugs the one most 
likely to be of service in simple meningitis. Iodide of potassium is frequently 
prescribed, though with doubtful advantage. Drainage of the subarachnoid 
space in cases of acute tubercular meningitis has been carried out by an 
opening made either in the lumbar or cervical spine, or preferably by trephining 
the occipital bone. Successful cases have been recorded, but we have no 
personal experience of the method. Operation if done at all should be 
performed before coma sets in. 

Chronic Meningitis. — A chronic inflammatory process, affecting more 
especially the convex surface of the brain, occurs occasionally during 
infancy, apparently also during intra-uterine life. In such cases the 
surface of the brain becomes adherent to the dura mater, a thickening of 
the membranes taking place resembling the pachymeningitis of adults. 
A membranous exudation may be thrown out, and blood may be effused. 
Carr has recorded x a case of this sort in an undoubted syphilitic child of 
nineteen months. It had suffered from repeated convulsions and was idiotic. 
At the post-mortem, there was no hydrocephalus, the dura mater was- lined 
by a membrane of a gelatinous appearance, the same gelatinous material 
covered the cortex and base. The brain weighed 18 oz., there were some 
areas of sclerosis bordering on the fissure of Sylvius. Such a condition may 
be associated with a chronic hydrocephalus. The symptoms present in such 
cases are frequently not distinctive, or they may be simply those of chronic 
hydrocephalus ; there may be defective intelligence or idiocy, probably also 
convulsions ; retraction of the head and rigidity and flexion of the limbs are 
likely to be present if the child lives any length of time. The etiology of 
such cases is doubtful: they are always suggestive of hereditary syphilis. 
As chronic hydrocephalus is often associated with the meningitis, a diagnosis 
of hydrocephalus is probably all that can be made during life. 

A meningitis during intra-uterine life, by interfering with the growth and 
development of the brain, may produce various results, such as hydrocephalus, 
mal-development, or an abnormally small brain. Thus in a case-' of Dr. 
T. Barlow's, in an infant dying at seven weeks of age, the head measured 
•only \o}> inches round, and the brain weighed only 9 drachms ; the convolutions 
were hardly recognisable over the greater part of the convexity, and the pia 
mater and cortex beneath it were invaded with calcareous plates; the 
choroid plexuses of the lateral ventricles were also partially calcified. In 
this case there seems to have been an intra-uterine meningitis, followed by 
calcification oi~ the effused lymph and some atrophy of the subjacent brain 
tissue. In a case recorded by Dr. E, Holt 3 in a child oi' thirteen months 
the symptoms were those of a chronic hydrocephalus, from which the child 
1 Lancet, January [895, p. i=,|. ol. xxxviii 

5 i< s, Dec. 188 



454 Diseases of the Nervous System 

had suffered since three months old. The enlargement of the head was 
only moderate ; there was some rigidity of the posterior cervical muscles, but 
no paresis or contractures in the limbs. At the post-mortem the dura mater 
was found firmly adherent to the convexity of the brain : lymph and blood had 
been poured out on the surface. All the cavities of the brain were dilated. 
See also Sclerosis of Brain. 

Hy drocephalus 

Acute Hydrocephalus occurs only in association with an acute menin- 
gitis. In the majority of cases of acute meningitis, whether tubercular or 
simple, there is an excess of fluid in the lateral ventricles, the result of an 
intra-ventricular meningitis, and a consequent excessive exudation from the 
vessels of the choroid plexus. In exceptional cases the meningitis is con- 
fined to the ventricles. In those rare cases where an acute or subacute 
meningitis ends in recovery a chronic hydrocephalus may be left ; in these 
cases the head slowly enlarges in succession to the symptoms of a meningitis. 
Excess of fluid may be found in the subarachnoid space in acute meningitis. 

Chronic Hydrocephalus. — The accumulation of an excess of fluid in 
the ventricles of the brain is by no means an uncommon condition in infants 
and children, (i) It may be congenital, the accumulation taking place before 
birth, and it may give rise to difficulty in the extraction of the head. (2) It 
may follow an acute meningitis or subacute meningitis. (3) It may arise 
without any apparent cause. (4) It may be the result of a tumour, as for 
instance a tumour of the cerebellum, compressing the veins of Galen, and in 
other ways interfering with the circulation. 

In the majority of cases the child is born healthy, and the enlargement 
of the head is first noticed when the infant is a few weeks to a few months 
old ; usually no cause can be assigned, but some of the cases are syphilitic, 
and it is not improbable that syphilis plays an important part in the pro- 
duction of hydrocephalus by means of a subacute basal meningitis. En- 
largement of the head is preceded in a few cases by distinct cerebral symptoms, 
as convulsions, fever, and drowsiness, so as to suggest the probability of the 
meningitis perhaps being local rather than general. As the fluid accumulates 
in the ventricles the head enlarges, the bones forming the vault of the cranium 
become thinned and open out, so that the fontanelles are enlarged and the 
edges of the bones at the sutures are separated from one another (see fig. 88). 
The fontanelles are bulged and have a fluctuating feel, the occipital and 
parietal bones may be so thin that moderate pressure with the finger is suffi- 
cient to bulge them in. The cranium assumes a spherical form, and its 
increased size contrasts with the child's face, which may be thin and sunken, 
giving the child a characteristic appearance. The forehead is rounded, and 
projects so as to overhang the face ; the parietal and occipital bones assume 
a similar shape, so that the head has a globular or rounded form. There 
may be nystagmus. The general rounded contour is broken by the 
prominence of the frontal and parietal eminences ; at these spots the bone 
is thick and solid, and consequently cannot be bulged out like the thinner 
bone elsewhere. The skin of the forehead and scalp is thin and shiny from 
being stretched, and the cutaneous veins are distended, especially when the 
infant cries ; the eyes project : their axes may be divergent, and there may 



Chronic Hydrocephalus 



455 



be difficulty in closing the eyelids. The infant cannot raise its head, and if 
propped up the head rolls over in a helpless sort of way. The condition of 
the intellect varies considerably : in the majority of cases, where the hydro- 
cephalus is moderate in degree, the intellectual powers are surprisingly good 
when it is considered what amount of compression and flattening out the 
grey matter on the surface of the brain is exposed to by the accumulation of 
fluid in the lateral ventricles. In extreme cases there is certain to be marked 
intellectual defect, perhaps amounting to idiocy. The limbs are mostly 
paretic, and the lower extremities especially are rigid, and flexed upon the 
abdomen : permanent contractures are apt to follow, a result probably due 




Fig. 88.— Outline of Head in Chronic Hydrocephalus, a a, frontal bones ; b .'■, parietal ! ones. 



to compression of the pons. Atrophy of the optic nerves max take place 
from compression or stretching of the optic tracts or commissure. The 
course of the disease is usually chronic, and infants will live for months or 
even years, but ordinarily they gradually waste and die. The child shown 
in fig. 89, who was 6jj years of age, had suffered from chronic hydrocephalus 
since three months old ; he was well nourished ; his head measured 
31^ inches in circumference ; he was a complete idiot. The legs weie bent 
at the knee and flexed on the abdomen, but the spasm of the muscles varied 
from time to time ; the hands were kept closed, and the elbows were flexed 
and more or less rigid. YVe have known recovery to take place, even after 
rigidity of the legs has come on. 



456 



Diseases of the Nervous System 



In older children, when the disease comes on after the closure of the fon- 
tanelles, the head enlarges more gradually, thinning the bones and even open- 
ing up the fontanelles and sutures ; in these cases the hydrocephalus is mostly 
due to a cerebellar tumour ; blindness and imbecility gradually supervene. 

Diagnosis. — This is not difficult when the disease is well advanced ; 
difficulty, however, occurs in the early stages when the accumulation of fluid 
is small, and when hydrocephalus may be mistaken for a rickety skull, or 
simply a large head without distention of the lateral ventricles such as occurs 
in rickets. The friends of patients often ask whether a child who has a large 
head has ' water on the brain.' A diagnosis can only be made when the head 
enlarges under observation, the bones becoming thinned, the fontanelles 
bulged and fluctuating ; the globular shape which it assumes distinguishes 
it from the misshapen head of a typical case of rickets with the prominent 

eminences, flattened vertex, and 
thick edges of the bones. In the 
simply enlarged head, from the 
presence of an abnormally enlarged 
brain, there is no opening out and 
bulging at the fontanelles, nor usu- 
ally any evidence of a thin skull. 

Morbid Anatomy. — In those 
cases in which the excessive quan- 
tity of fluid in the ventricles is 
caused by a cerebellar tumour the 
mechanism is tolerably clear, for 
any stretching of the tentorium 
cerebelli must compress the straight 
sinus which runs along at the base 
of the falx cerebri, and conse- 
quently check the onward flow of 
blood in the veins of Galen and 
inferior longitudinal sinus. As the 
veins of Galen return the blood of 
the choroid plexus, it is easy to 
understand how a chronic hydro- 
cephalus may be thus produced. In these cases the lateral ventricles are 
distended with a clear fluid of low specific gravity, the third and fourth 
ventricles join in the dilatation, and the iter is also enlarged. In those 
cases which form the majority, where no tumour is present, and no evi- 
dence of a past or present meningitis, the mechanism of the hydro- 
cephalus is by no means clear. In these cases the lateral ventricles and 
their horns may be enormously dilated, the grey matter on the surface 
is flattened out and reduced in some cases to the thickness of cardboard, 
the convolutions being lost or only traced with difficulty. The contained 
fluid is clear, of specific gravity about 1005, with a small quantity of albu- 
men and salts ; the third and fourth ventricles are dilated ; the pons is 
often flattened by the pressure of fluid in the fourth ventricle. The cause 
of this ponding up of fluid in the ventricles is by no means certain ; it has 
been attributed to the closure of the aperture by which the ventricles 




Fig. 



-Chronic Hydrocephalus in a boy aged 
64 years. 



Hypertrophy of the Brain 457 

communicate with the subarachnoid space, which is situated near the inferior 
boundary of the fourth ventricle (Hilton;. A local meningitis at this spot 
would readily seal up the opening. We doubt if this explanation suffices for 
those extreme cases of hydrocephalus so often met with : the mere obstruc- 
tion to the escape of fluid will hardly account for the accumulation of large 
quantities of fluid which must be secreted under great tension. It seems 
more likely that there should be some obstruction to the escape of blood 
from the choroid plexuses, or some lesion of the latter which gives rise to an 
excess of cerebro-spinal fluid being secreted. It must be remembered, 
however, that the fluid drawn off from cases of hydrocephalus is of much 
lower specific gravity than serum, or the fluid drawn from a chronic inflam- 
matory effusion, as in chronic pleurisy. 

Treatment. — rThe treatment of chronic hydrocephalus when once esta- 
blished is unfortunately unsatisfactory, and but little can be done to influence 
the progress of the disease. In any case in which there is reason to suspect 
syphilis some mercury should be given internally, and some ung. hydrarg. 
applied to the head, or strips of mercury plaister, to effect a moderate com- 
pression, while some of the drug will be absorbed. Some cases in infants 
appear to be benefited by this treatment ; but, presuming there is a chronic 
.syphilitic meningitis, it is by no means certain to be influenced by anti- 
syphilitic treatment. Both mercury and iodides should certainly be tried, 
■especially as there is no other drug which affords any chance of success. 
Some measure of success has been claimed for compression of the head by 
means of strips of plaister or an elastic bandage ; if it is decided to try this 
method its risks must be borne in mind. The circulation through the scalp 
is interfered with by its compression between the skull and bandage, the 
brain is also compressed between the skull and the fluid in the ventricles. 
We have seen extensive sloughing of the scalp in a case of hydrocephalus, 
the result of a too tightly applied elastic bandage. No real compression can 
be of any service, and is decidedly risky ; but a lightly applied bandage may 
be of use as a support. Puncture with one of Southey's canulae through 
the anterior fontanelle, avoiding the superior longitudinal sinus, offers more 
chance of at least temporary relief. It is usually harmless, though if too 
much be withdrawn there is a risk of collapse of the brain substance, with 
perhaps convulsions and sudden death. We have drawn off 12 oz. through 
one of Southey's canula:, but the fluid reaccumulated in a few days. 

Of other methods of treatment we have had no experience. Pott has 
treated chronic, hydrocephalus by incision and drainage, and Ranke by 
puncture and injection of tincture of iodine iogrms. diluted with 20 grms. o\ 
water. It cannot be said with much success. 

Hypertrophy of the Brain. — Rickety children often have abnormally 
large heads, a condition which is frequently attributed to 'water en the 
brain.' In reality such abnormally large heads are not hydrocepha 
their increased size being due in some cases 10 the prominent frontal and 
parietal eminences, but more often to an enlarged brain. The cause o( this 
hypertrophy is not known, and the nature of the enlargement in the bra 
liver, or spleen, which is apt to take place in rickets, is not clearly under- 
stood. In several cases coming under notice of children in their second and 
third years, with large heads, who have had rickets in a severe form and who 



458 



Diseases of the Nervous System 



have died in convulsions, the brains have been large, the convolutions well 
marked, the brain substance fairly firm, and the microscopical examinations 
revealed no change that we could detect. Such brains are usually very vas- 
cular, but, as death often takes place through convulsions, it is hardly safe to 
assert that the vascularity is anything more than a secondary effect, result- 
ing from the manner of death. In some cases the increase in size has been 
attributed to an increase of the connecting elements, the neuroglia, but it is 
needless to say it is a very difficult matter to decide if this is so in a brain 
in which the enlargement is general ; in our own cases, certainly, there was 
no striking change. It is certain that enlargement of the brain in these 
cases is not accompanied by any precocity of intellect ; indeed, it is rather the 
reverse, as such children are mostly backward, not only in physical, but also 
in mental development. If the quantity of brain matter is large, the quality 
is certainly poor. 

Atrophy of the Brain; Sclerosis of the Brain. — This condition is 
more often local than general, and is mostly secondary to some inflam- 
matory lesion or softening which has preceded it either during intra-uterine 
life or after birth. Among the local regions which suffer are the cerebrum 
or cerebellum, or one half of either ; a portion of a hemisphere may be 
atrophied, so that there is a marked depression where the convolutions 




Fig. 90.— Sclerosis of Brain. From a boy of twenty months. The convolutions have dis- 
appeared, the surface of the brain resembling a hob-nail liver (probably syphilitic). The 
openings which transmitted the meningo-cephalic vessels appear as black points. 



are absent, which has been called Porcnccphahis ; or almost any part of the 
brain may be affected. In rare cases the whole or greater part of the brain 
is shrunken and indurated, as the result of a meningoencephalitis occurring 
during intra-uterine life, or shortly after birth ; such cases are probably 
syphilitic. As an instance of an atrophied or sclerosed brain the following 
may be mentioned : 

Atrophic Brain. — A child who died at the age of twenty months had been a complete 
idiot from his birth, and had suffered from convulsions ; he was blind and deaf; the legs 
and arms were drawn up and stiff. At the post-mortem the brain was found hard and 
shrunken over the convex surface ; the convolutions had completely disappeared, the sur- 



Atrophy of the Brain 



459 



face being simply grooved by the vessels and granular like a ' cirrhosed ' liver ; at the base 
and median surfaces the convolutions were fairly well marked. The pia mater consisted 
of many tortuous vessels, which could be dissected off. On vertical section it was seen 
that the grey matter and white matter also were hard and shrunken, and hardly dis- 
tinguishable from one another. Microscopical examination showed an increase of con- 
nective tissue and an absence of nerve elements. There was descending degeneration in 
the pons and cord (see fig. 90). 

The brain may be of abnormally small size, and yet the brain substance 
normal ; in such cases there is usually more or less mental defect. 

In some cases of children who have suffered from chronic wasting 
secondary to gastro-intestinal atrophy, during the last few weeks of life the 
lower limbs become more or less flexed and rigid and the abdomen some- 
what retracted. At the ftost-mortem the cerebral hemispheres are partially 
shrunken and an excessive quantity of fluid is present in the subdural and 
subarachnoid spaces. Presumably this atrophy is secondary to malnutrition 
the result of failure of the digestive powers. 



rfAriflfc, 




Fig. 91.— Showing Atrophy of left side of the Cerebrum. The right lobe of the cerebellum 
is slightly smaller than the left 

In the following curious case, atrophy or shrinking of one half oi the brain 
appeared to follow a fall on the head : 

Atrophy of a Cerebral Hemisphere. — Bernard II., sixteen months, admitted to the 
Children's Hospital, April 1803. The mother states the boy was perfectly healthy, and 
had the use' of his limbs up to fourteen weeks ago, when he accidentally fell off a table, sti 1 
the left side of his forehead on the floor. He was picked up unconscious, and remained 



460 



Diseases of the Nervous System 



-so for three hours ; on consciousness returning he was convulsed. The next day he was 
again convulsed and again became unconscious, in which condition he remained for three 
weeks. At the end of this time he regained consciousness, and it was found that his 
right side was paralysed. On admission he was a well-nourished child, his skull was well 
shaped and symmetrical, his right arm and leg were in a condition of spastic paralysis, 
resisting any attempt to extend them ; there was no squint, but slight nystagmus. He 
was very fretful and not intelligent. As it was supposed, there was a clot of blood com- 
pressing the left hemisphere ; it was decided to explore. On trephining the dura was 
purplish in colour and partially calcified on dividing it ; much clear fluid escaped ; there 
was evidently an enlarged subdural space. The child sank twenty-four hours after the 
operation. At the post-mortem it was noted both sides of the skull were symmetrical, the 
left hemisphere was much smaller than the right (see figs. 91 and 92), the right side of 
the cerebellum slightly smaller than the left. There was no trace of a past menin- 
gitis or haemorrhage, and 
no thrombosis or embo- 
lism. The convolutions on 
the left hemisphere were 
wasted, but not markedly 
so, the pia mater peeled 
off readily ; vertical sec- 
tions, after hardening in 
Muller's fluid, showed 
there had been a general 
shrinking of the left hemi- 
sphere, or, at any rate, all 
parts were proportionately 
smaller than the right ; 
there was some hyper- 
trophy of the right side. 
Microscopical examination showed there had been a chronic inflammatory induration of 
the left hemisphere. It was suggested that the case was really congenital, the history 
being misleading ; against this view-, however, is the fact that the skull was symmetrical and 
was no smaller on the left side than the right ; and the mother was very positive with 
regard to his being quite well up to the time of the accident. He had not suffered 
from convulsions previously to the fall. 



It 




Fig. 92. — Transverse Section of Brain shown in fig. qr. The 
space between the left side of the cerebrum and the dura 
mater, shown by dotted line, contained fluid. 



Tumours of the Brain 

While cerebral tumours are by no means uncommon during childhood, 
the different varieties found are few. In the vast majority of cases the tumour 
or tumours consist of caseous masses formed by a local tubercular process. 
These tubercular masses especially have a marked predilection for the 
cerebellum, but are found also comparatively frequently in the pons, basal 
ganglia, and cerebral hemispheres, both on the surface and in the connecting 
white substance. Cysts of uncertain origin are also found, especially in the 
cerebellum. The pons seems the favourite seat of gliomas when they occur. 
Other new growths, such as epithelial carcinomata, may be occasionally 
found growing from the choroid plexus or pia mater. Periosteal sarcomata 
growing from the bone are not uncommon, compressing the grey matter. 
No age is exempt ; tubercular tumours have been found in infants a few 
months old, though they are more common somewhat later. Demme found 
a cheesy mass in the cerebellum of a newly born child, so that tumours may 
form during intra-uterine life. Little is known as to the cause which de- 
termines the growth in the brain or its coverings ; it appears certain, how- 



Tumours of the Brain 461 

ever, that an injury acts as an exciting cause. A fall or blow on the head is 
followed in the course of a few weeks or months by cerebral symptoms. On 
the fatal termination a cheesy tumour is found in the cerebellum. How the 
injury can have given rise to this can only be surmised ; possibly there is a 
local bruising and punctiform haemorrhage. The most common tumour to 
follow a blow is a tubercular tumour, but then tubercular tumours are vastly 
more common than any others ; nevertheless a cyst or a syphiloma or a 
periosteal sarcoma does appear to follow a blow at times. 

Symptoms. — The ge?ieral symptoms include : (1) persistent headache ; 
(2) paroxysmal vomiting ; (3) optic neuritis ; (4) convulsions. The local sym- 
ptoms are those caused by the tumour interfering with the function of some 
region, and causing some local paralysis or spasm, or incoordination of move- 
ments, or pressure on some venous channel and consequent disturbance of 
the circulation. 

Headache is almost constantly present, though in young children, who are 
unable to complain or describe their feelings, its presence or absence cannot 
be determined. Its locality may help to indicate the seat of the lesion, 
but for this purpose it is an uncertain guide ; it may be either frontal or 
occipital in tumours of the cerebellum, and it may shift about from time to 
time, but if fixed and constant at one spot it is of some value for localisation. 
It is usually tolerably constant, or not absent for long together, but is apt to 
be much worse at some times than others. It is mostly made worse by move- 
ment, and when the child is up and about, and is better when it is at rest and 
lying down. Percussion over the seat of the headache usually makes it 
worse or gives acute pain, but it is seldom of any diagnostic value in 
children. The headaches most likely to be mistaken for those due to a tumour 
are the hysteroid headaches, which are often very persistent and severe. 

Vomiting is a frequent and very characteristic symptom, and may be present 
in tumours of all parts of the brain, especially of the cerebellum, pons, and 
medulla, and when the root of the pneumo-gastric is involved. The vomiting 
usually comes on suddenly without warning, and without much nausea, and 
may be repeated daily or several times a week without any cause being de- 
tected : such vomiting is very suggestive of cerebral disease, though it must 
not be forgotten that hysterical vomiting also occurs, especially in girls about 
puberty. There may be nausea and constant sickness, with much retching, 
in the later stages of a cerebral tumour. It is often paroxysmal, coming on 
and lasting for several days continuously, being not amenable to treatment, 
and then suddenly improving. 

Optic neuritis occurs in the majority of cases sooner or later, and is 
especially common in tumours of the cerebellum, less so in those ot the frontal 
regions. The discs become swollen, so that on examination the edges appear 
at first blurred, and then all distinction between the edges of the disc and 
retina is lost, even to the direct method of examination. The veins become 
distended and tortuous, and haemorrhages occur ; finally, after some months. 
the discs gradually pass into a condition of atrophy. The exact cause of 
optic neuritis is uncertain ; it occurs in association with tumours in all parts 
of the brain, but maybe absent from first to last ; it has been known to occur 
in otitis and in disease of the cord without any discoverable cerebral lesion. 
In a case of our own, of acute otitis, their was optic neuritis, and no lesion of 



462 Diseases of the Nervous System 

the brain was discovered post mortem. The neuritis appears to be in some 
cases a descending one, passing along the sheath of the optic tract and pro- 
ducing an intense inflammation at the papilla ; but this can hardly be the 
case often : it is much more likely to be a reflex inflammation, such as herpes 
facialis, which so often appears on the lips and face in inflammatory con- 
ditions of the respiratory tract. Optic neuritis, it is important to remember, 
may occur without any loss of sight, though as atrophy sets in the sight is 
certain to be damaged It is often of great diagnostic importance, its presence 
being of much value as an indication of a cerebral lesion, though its absence 
in any given case where other symptoms point to some cerebral lesion does 
not necessarily negative the diagnosis. Optic neuritis may come on either 
early or late in the disease. 

Giddiness is often complained of, most commonly in disease of the cere- 
bellum and pons. 

Convulsions. — The first symptom may be a convulsion, which may never 
be repeated, or convulsions maybe frequent during the course of the disease, 
and may occur in the case of tumours of any part, but more especially when 
the growth involves or compresses the motor cortical centres than when the 
cerebellum is involved. Such convulsions may be epileptiform, but without 
aura. In these cases the nature of the aura and the commencement of the 
fits in some special part afford an indication of the seat of the tumour 
which is situated in the cortex. The convulsions, which commence in one 
part, may quickly become general. 

Paralysis. — The various paralyses and other local symptoms will be 
referred to later on under the regional symptoms. 

Tumours of the Cerebellum. — One of the common seats for a cheesy 
mass is in the lateral lobes of the cerebellum. It is not uncommon to find 
these masses varying in size from a pea upwards in the lateral lobes of a 
child who has died of tubercular meningitis, without any definite signs of their 
presence having been given during life. In cases of cerebellar tumour which 
have proved fatal, a cheesy mass may be found which has, perhaps, become 
adherent to the posterior fossa of the skull and tentorium, and has, very likely, 
extended across the middle line, encroaching on the medulla, and so compressed 
the motor tracts passing downwards to the cord. Another pressure effect is the 
compression of the straight sinus by the stretching of the tentorium, and a 
consequent pounding up of the blood in the venae Galeni, and chronic effusion 
of fluid in the lateral ventricles. A large cerebellar tumour is almost certain 
to be accompanied by chronic hydrocephalus, the lateral ventricles are 
greatly dilated, the skull thinned, and perhaps the pons may be more or less 
compressed and flattened by the pressure of the fluid. A tumour of the 
middle lobe is more likely to compress the motor tracts in the floor of the 
fourth ventricle than one in the lateral lobes. A simple cyst in the cerebellum 
is not uncommon. 

Symptoms. — The history obtained from the friends usually includes 
headache, more or less vomiting, and squint. In young children it may 
be that enlargement of the head and more or less blindness are early 
noticed. 

An examination of the patient elicits the fact that the headache is either 
frontal or occipital, and of varying intensity ; in one of our cases the pain was 



Tumours of the Cerebellum 463 

always referred to the right occipital region, and the boy would sometimes be 
found asleep with his hand placed on this spot. At the post-mortem exa- 
mination a large sarcomatous tumour was found in the right lobe of the 
cerebellum. It is, however, not common for the patient to be able to 
localise the lesion in this way. The headache is usually described as an 
' ache ' rather than as a sharp pain, but in some cases we have known it to 
be intense, suggesting the presence of meningitis. The vomiting, like 
cerebral vomiting generally, is fitful and uncertain ; as a rule it is not persistent, 
and it comes and goes in an erratic manner. It is rarely troublesome when 
the patient is at rest in bed. Internal squint is in our experience an early 
and frequent symptom ; it is not always double, and sometimes one eye is 
affected more than the other ; the strabismus is due to a paresis of the sixth 
nerves, and not to a spastic condition of the internal recti. In one case 
coming under our notice a boy who suffered from headache, and who 
had developed an internal squint, was operated on for the strabismus by a 
surgeon ; the latter, however, altered his opinion with regard to the case when 
he discovered optic neuritis to be present. The boy had a cerebellar tumour. 
Optic neuritis is a common and early symptom ; greater or less limitation of 
the field of vision and blindness usually follow. 

In all cases there is sooner or later a peculiar gait or walk, due to more 
or less weakness in the legs,, This peculiar gait is often described as 
'ataxic,' and ' cerebellar ataxia' is sometimes said to be present ; or there is 
a staggering gait, or a difficulty in maintaining the equilibrium. Sometimes 
attention is called to a patient's supposed tendency to fall forward or back- 
ward, or to one side. Now it is certainly true that the patient's friends often 
give a history of staggering or easily falling, and if a child with a cerebellar 
tumour is got out of bed and made to promenade up and down the ward, he 
will most likely sway and easily fall, or he may start forward, as if wound up, 
in a clumsy headlong way. But we confess we are sceptical with regard to the 
existence of a special 'cerebellar ataxia,' and we cannot call to mind any case 
in which we could satisfy ourselves that it existed. The gait of a child with a 
cerebellar tumour is very much that of a child learning to walk ; there is a 
good deal of clumsiness and a great readiness to fall, but this is due to a 
weakness or paresis of the limbs, and not to ataxia. When there is a spastic 
rigidity, with an over-action of the gastrocnemius group and of the flexors o\ 
the knee, there is necessarily a clumsy gait with a tendency to fall forward. 
We have never been able to satisfy ourselves that in any given case, apart 
from the results of a spastic rigidity, there was a tendency to fall on cine side 
or in any given direction. 

An increased tendon-reflex is indeed the rule, but occasionally it is 
certainly absent or diminished. We cannot give a reason for this, and we 
doubt the correctness of the one that has been given, namely, that it is due 
to a destructive lesion of the cerebellum. 

Enlargement of the head is common : this takes place early in young 
children on account of the readiness with which the cranial bones vie', 
the internal pressure, but it may take place also in children oi six or seven 
years of age. 

Eclampsia is not uncommon; the general type is that which consists 
entirely of tonic spasms; there is retraction oi the head, rigiditj of the 



464 Diseases of the Nervous System 

limbs, and frequently opisthotonos. Death may take place in one of these 
attacks on account of the spasms of the respiratory muscles. 

Facial paralysis, mostly single and slight, and also nystagmus, are 
among the occasional symptoms. 

In the later stages, should the patient survive, the limbs pass into a 
condition of semi-rigidity ; at first this is temporary, but later it becomes 
permanent. The arms as well as the legs are affected, while the head 
becomes more retracted and fixed. Marked wasting is certain to ensue in 
the late stages, and various trophic changes, such as sloughing of the eyes 
and bedsores, generally follow. 

Are the above symptoms the result of a destruction of a portion of the 
cerebellum ? In our view the answer must be in the negative ; they are the 
symptoms produced by a gradually increasing dropsy of the ventricles, due 
to the tumour of the cerebellum stretching the tentorium cerebelli, and 
obstructing the return of blood from the veins which drain the ventricles, 
and which empty themselves into the straight sinus. If the cerebellar 
tumour produces any symptoms per se, they are masked by those produced 
by the hydrocephalus. In connection with this we may bear in mind that 
cases have been reported in which there has been a congenital absence of 
one half of the cerebellum, and in which no symptoms have been observed 
during life. As a result of this obstruction of the venae Galeni, fluid is pent 
up in the lateral ventricles and also in the third and fourth, and the sur- 
rounding parts are compressed. All the ventricles become dilated, the 
aqueduct of Sylvius becomes large enough to admit the forefinger, and the 
pons is flattened. The sixth nerves are compressed beneath the pons, giving 
rise to internal strabismus, and the facial may be compressed also. Pressure 
of the fluid on the motor tracts gives rise to the paresis of the limbs and 
consequently to staggering gait, and at a later stage to spastic rigidity. The 
headache is presumably caused by the stretching of the tentorium. "Whether 
the choked disc is the result of a reflex irritation, or of a disturbance of the 
circulation, is an open question. It is curious to note that in chronic hydro- 
cephalus, where the large quantity of fluid is due to an excessive secretion 
without any obstruction of the veins, there is only exceptionally paralysis of 
the sixth nerves and rarely optic neuritis, though there may be blindness. 
These cases, however, are either congenital or commence in early infancy 
before the sutures have united, so that tension is relieved by the enlargement 
of the skull. 

With regard to the differential diagnosis between hydrocephalus, the 
result of the growth of a cerebellar tumour, and hydrocephalus due to sub- 
acute meningitis, or to a chronic simple effusion, difficulties are certain to 
occur. In infants or young children suffering from enlargement of the head r 
vomiting, and rigidity of the muscles of the neck with retraction of the head, 
we may be in doubt whether the child suffers from a chronic basal meningitis 
or from a cerebellar tumour. In these cases the temperature might help, 
there being in all probability an evening rise of a few degrees in meningitis r 
while the presence of optic neuritis would favour the diagnosis of tumour. 
In simple effusion the case is usually very chronic, and optic neuritis rarely 
occurs. 

Our experience of tumours of the middle lobe of the cerebellum is very 



Tumours of tJie Pons and Medulla 465 

limited. We should be inclined to expect that the most prominent symptoms 
would be those caused by direct pressure on the floor of the fourth ventricle. 
This certainly was the case in a patient of our colleague, Dr. H. R. Hutton, 
the most marked symptoms being retraction of the head and neck, coming 
on in paroxysms and accompanied by severe pain, apparently due to the 
cramp of the muscles. At the post-mortem examination a cystic tumour of 
the inferior vermiform process was found, which had pressed upon and 
flattened the floor of the fourth ventricle. 

To sum up as regards diagnosis. The symptoms of a tumour of one of 
the lateral lobes of the cerebellum are those of a gradually increasing hydro- 
cephalus, with the addition of optic neuritis and vomiting. It is only occa- 
sionally possible to say on which side the tumour is situated, and then only 
by means of the pain, which may be referred to the actual spot. The so- 
called ataxic gait is due to paresis or semi-rigidity of the limbs. When the 
tumour occupies the middle lobe the most marked symptoms are retraction 
of the head and neck, arching of the back and exaggerated tendon reflex. 

Tumours of the Pons and Medulla. — Tubercular masses not infre- 
quently invade the pons, being situated in the central part, or small masses 
may be found in the floor of the fourth ventricle. They are apt to cause 
symptoms, less, perhaps, by their direct pressure effects, as they grow but 
slowly, than from the softening which often surrounds them ; yet at the post- 
mortem, when the size of the cheesy mass is discovered, we have often been 
surprised how little paralysis was present during life. Gliomas of the pons 
are not rare in older children. 

Symptoms. — The combination of symptoms in disease of the pons varies 
much in different cases : this is due to the close proximity of the motor 
tracts and the centres of various cranial nerves. The paralyses produced by 
disease of the pons are apt to be bilateral, on account of the right and left 
motor paths and nerve centres being near together. The symptoms vary 
according to the position of the lesion in the pons ; thus in a case of our 
own, in which a glioma commenced in the right lower border, there 
was 'crossed paralysis,' viz. a left hemiparesis with paralysis of the right 
external rectus, and right facial paralysis, optic neuritis, and vomiting. 
Cheesy masses are often more centrally situated, and may after a while 
involve the medulla ; there may then be double facial paralysis, perhaps 
more marked on one side than the other ; the saliva dribbles from the mouth, 
the speech is thick, and there may be difficulty in swallowing. There 
may be paresis and rigidity of the limbs, squint, and sloughing of the cornea 
from interference with the fifth. 

Basal Ganglia and Internal Capsule. — Cheesy masses may be present 
in the caudate or lenticular nucleus or thalamus, but they only produce a 
definite hemiplegia when they involve the internal capsule. In one ol our 
own cases a villous growth from the choroid plexus compressed the left 
thalamus and internal capsule, and produced a paresis of the right arm and 
leg, with marked rhythmical shaking movements when voluntary action was 
attempted, so much so that his mother said his arm used to 'work like a 
clock;' contractures, facial paralysis, and optic neuritis supervened before 
death. The rhythmical tremors were no doubt produced by gradual pies- 
sure on the motor path which passes along the internal capsule. In children 

it 11 



466 Diseases of tJie Nervous System 

there is rarely loss of sensation : this occurred, however, in one of our cases, 
in which two large cheesy masses involved the whole of the posterior limb of 
the internal capsule, the arm and leg of the opposite side being contracted 
and anaesthetic. 

Tumours of the Cortical Layer. — Irritation of any part of the motor 
area of the cortex, which includes the ascending frontal and parietal con- 
volutions and the anterior portion of the superior parietal lobule, gives rise 
to convulsions, which begin in the arm, leg, or face, according to the part 
affected. Destruction of this region, as by softening following embolism, 
or the presence of a tumour, gives rise to a hemiplegia affecting the face, 
arm, and leg, a partial destruction giving rise to a partial paralysis. The 
presence of a syphiloma, a tubercular mass, or pressure by a tumour growing 
from the membranes, is likely to give rise to epileptiform seizures, the con- 
vulsions starting in the arm, leg, or face, though they are not necessarily 
confined to the limb in which they start, but may become general. In the 
later stages a hemiplegia results. 

Tumours of the Frontal Xiobe produce no paralysis unless they encroach 
upon the ascending frontal convolution : in that case they may produce a 
paresis of the leg, arm, and face, according to the part involved. A tumour 
involving the posterior third of the left frontal convolution causes aphasia. 

Prognosis. — The prognosis in cerebral tumours is exceedingly unfavour- 
able, whatever their nature may be, unless perhaps syphilis may be excepted. 
Undoubtedly tubercular masses may cease to spread and become cretaceous, 
though against this must be set off the chance that other masses may form, 
or the child die of tubercular meningitis or tubercle elsewhere. Every other 
form of tumour is certain to progress from bad to worse. In the majority 
of cases the progress is slow, often lasting over a year or more. Death may 
supervene from intercurrent disease, as tubercular meningitis, or other form 
of tubercle ; it may be sudden in tumours of the pons and cerebellum, or it 
may be -exceedingly slow, as in cases of cerebellar tumour and chronic 
hydrocephalus. Occasionally cases in which the diagnosis of tumour is 
made partially recover, or remain stationary for many years. Gowers 
records a case of a girl of fifteen years who suffered from hemiplegia, head- 
ache, hemianopia, and optic neuritis of gradual onset ; she gradually re- 
covered, except the hemianopia and paresis of arm, and was well, with these 
exceptions, six years after. In a case of a girl aged ten years, who was 
seen by the late Dr. Ross and one of ourselves, there could be little doubt 
that there was a cerebellar tumour, as there was optic neuritis and spastic 
condition of both legs ; she eventually recovered while under the care of a 
quack, but became quite blind. 

It is not uncommon to find cretaceous masses in the brain, evidently the 
result of the shrivelling up of a tubercular mass. This was so in the follow- 
ing case : 

Cheesy Tumour of Cerebellum ; Temporary Recovery. — A boy aged 11 years was 
admitted into hospital, November i83i, with internal squint, optic neuritis, and almost 
complete blindness. He was intelligent and walked about ; there were no signs of any 
paralysis, he had no headache or vomiting ; during his stay he got better, and was dis- 
charged (January 1882) apparently in good health, though quite blind from optic atrophy. 
He was readmitted February 1883, having suffered for six months with pain in his head. 



Tumours of the Cerebellum 467 

and recently he had lost power in the right side ; the right elbow was semi-flexed, the 
wrist pronated and flexed, the fingers over-extended, except at the metacarpal joints ; the 
knee was bent, and the ankle in the position of equino-varus ; there was also loss of sen- 
sation on the right side, and the boy had some difficulty in finding the right arm with his 
left. In March there was some difficulty in swallowing, with paresis of left side of face 
and arm, followed by death. At the post-mortem there was a small cyst, with thickened 
cretaceous wall on the inferior surface of the right frontal lobe, evidently the remains of 
a tubercular mass ; there was a cheesy mass involving the left caudate nucleus and optic 
thalamus and internal capsule ; there was a second cheesy mass involving the lenticular 
nucleus and internal capsule of the right side. In this case there is no doubt there was a 
cheesy mass in the right pre-frontal lobe on the inferior surface, which gave rise to optic 
neuritis and internal squint, and which passed into a quiescent state ; subsequently other 
tubercular masses formed, which, with a general tuberculosis, caused his death. 

Diagnosis. — The most important point to be decided is whether there is 
a cerebral lesion, or the symptoms are due to functional disease ; the question 
as to the nature and seat of the lesion is of less practical importance. The 
cases which at first sight present a superficial resemblance to cases of 
cerebral tumour are those of chronic headaches in children at puberty, which 
are often severe, and are sometimes accompanied by vomiting or nausea. 
The latter, however, are never accompanied by optic neuritis or by sudden 
vomiting, are rarely acutely painful, and are improved, or got rid of for a time, 
"by active exercise in the open air. The headaches of a cerebral tumour are 
severe, sometimes make the patient scream with pain, and are made worse 
by active exercise. 

The vomiting in a case of cerebral tumour is causeless, coming on the 
first thing in the morning, is perhaps constant for a day or two or more, 
then passes away for a while without any apparent reason. The paralyses 
of hysteria are not often hemiplegic, being more often paraplegic, and are 
never accompanied by optic neuritis. 

When fits are present there may be a difficulty in distinguishing between 
epilepsy and a tumour, especially as a hemiparesis is apt to remain after a 
fit. In these cases, if the convulsions have constantly a local commencement, 
they are probably due to a tumour, and later on optic neuritis or some 
paralysis would decide the diagnosis. The presence of more tumours than 
one may make the differential diagnosis difficult. 

Treatment. — Except in the case of syphilomas of the brain, the treatment 
of cerebral tumours by medicines resolves itself into a treatment of symptoms. 
Wherever there is the least chance of the tumour being syphilitic, iodide of 
potassium should be given in full doses; though in children syphilitic disease 
of the brain is rare. If it is supposed that the tumour is tubercular, cod 
liver oil and iodide of iron may be prescribed, while the child is kept at rest, 
and placed under the most careful hygiene. 

For the headaches, bromides, Indian hemp, and opium may have 10 be 
prescribed. The vomiting, which is so often troublesome, must be treated 
by perfect rest in bed, peptonised milk or ice thinks being given in small 
quantities. Hydrocyanic acid may be given. The vomiting is exceedingly 
erratic, coming and going without any apparent cause. In some tumours at 
least the question of operation may be entertained ,see infra^. 

Cerebral Abscess. — In children, as in adults, the common cause o\ 
abscess of the brain is injury or ear disease ; less often it is the result of 

11 11 1 



468 Diseases of the Nervous System 

suppuration in a distant part, as an empyema or abscess of lung. Abscess 
is most common in the cerebrum, less frequent in the cerebellum or pons. 

Symptoms. — The early symptoms are those more or less of meningitis, 
namely headache, fever, vomiting, and perhaps convulsions ; they may, how- 
ever, be very slight and readily overlooked. The later symptoms, those of the 
chronic stage, vary according to the seat of the abscess, and are more or less 
those of a cerebral tumour, including optic neuritis, headache, vomiting, 
convulsions, and varying paralyses, also perhaps hectic, and emaciation. The 
diagnosis of abscess from meningitis or tumour is sometimes very difficult, 
as the following cases show. A girl of two years of age who was admitted 
into hospital under Dr. Hutton, had had a discharge from her right ear for 
three months, but was otherwise well and strong, till fourteen days before 
admission, when she had a right-sided convulsion lasting four hours, followed 
by unconsciousness ; four days afterwards she had a similar attack : she 
squinted, and was more or less blind after it. On admission there was 
almost complete motor and sensory paralysis of the right arm and leg, with 
loss of sensation on the left side of the face and ptosis on the left ; she became 
convulsed, the convulsions beginning in the right side, and was unconscious 
before death. At the post-mortem an abscess cavity was found in the le'ft 
temporo-sphenoidal lobe, extending into the occipital lobe and reaching the 
internal capsule : it contained three ounces of pus. The left tympanum was 
full of pus. In the following case the abscess followed a perforating wound 
of the orbit. A. boy aged six years was playing in a hayfield when by accident 
he was wounded above the left eye with the prong of a hayfork ; the eye 
swelled, but no external wound was found. During the next few weeks he 
was irritable and frequently vomited. Six months after he was brought for 
advice, as his sight was failing. On admission he was quite blind (atrophy 
of discs) and somewhat dull of comprehension ; he could walk well ; the right 
hand was weak, but not paralysed ; he remained much the same for a month, 
when he died suddenly. At the post-mortem the left frontal lobe was larger 
than that of the opposite side, its convolutions, including the superior, middle, 
and inferior, with more or less of the ascending frontal and parietal, flattened ; 
its inferior surface was adherent to the orbital plate and of a yellow tinge ; 
and there was an abscess containing four or five ounces of greenish pus. It 
was clear there had been a penetrating wound through the orbital plate into 
the brain. 

Treatment. — When pus has formed there is little hope in any method of 
treatment, except operation. 

Surgical Treatment of Cerebral Lesions. — Our knowledge of the operative 
treatment of tumours of the brain is still very limited, but enough has been 
learnt to justify a short account of the subject being given here. At present 
only those growths which lie on or near the surface of the cerebrum have 
been successfully dealt with ; tumours at the base of the brain, or involving- 
the basal ganglia, may be looked upon as inaccessible to surgery at present, 
and, though cerebellar growths are not beyond our reach, but little has yet 
been done for their removal. Surgery chiefly deals with growths situated in 
the motor area of the cortex, since the localisation of the tumour is most 
satisfactorily to be made out in this region. Again, only those growths 
which are of limited size are suitable for removal, since the destruction or 



Cerebral Abscess 469 

disturbance of large areas of the brain would lead to as great evils as the 
tumour itself. Assuming that the presence and exact position of a tumour 
have been ascertained by the symptoms presented, the following are the 
steps to be taken for its removal. If time permits, at least twenty-four hours 
should be devoted to preparation of the patient for the operation. The 
entire scalp should be shaved and thoroughly cleansed with turpentine ; after 
this a compress soaked in solution of corrosive sublimate, 1 in 3,000, or 
carbolic acid, 1 in 40, should be kept applied to the head for an hour before 
operation. The utmost precautions should be taken to have all instruments, 
and anything likely to come into contact with the field of operation, thoroughly 
aseptic. After the child has been anaesthetised, a large flap of integument, 
having its centre over the seat of the tumour, should be reflected and the 
bone laid bare. Next a large circle of bone should be removed with a trephine 
or gouge, or saw, and the dura mater exposed : the opening must then be 
enlarged by cutting forceps or saw as may be required. All bleeding must be 
arrested. The surface of the dura mater should then be carefully examined 
as to its colour, as to the presence of pulsation, and as to any tendency to pro- 
trusion through the aperture in the skull. We have noticed in a case 01 
cerebral tumour thinning of the bone over the seat of the growth, with en- 
gorgement of the diploic vessels, but this can only be expected to be seen 
when the growth is large and superficial. Should the tumour be extra-dural, 
its removal may be now accomplished ; but if it is truly cerebral, a crucial 
incision should be made in the membrane, and the surface of the brain 
inspected and felt with the finger for evidence, either visible or palpable, ot 
the mass ; if the growth is seen, its size and connections should be studied, 
and the question of the possibility of its removal decided upon. If it is 
determined to proceed with the operation, the substance of the cortex must 
be separated from the growth, and the mass removed with as little injury 
as possible, both to brain substance and to the vessels of the part. If there is 
softening (encephalitis) of the brain round the growth, the prognosis is bad, 
but any actually disintegrated brain should be removed. All bleeding is then 
to be arrested, the dura mater sutured over the brain, and the portion of skull 
removed, which should have been kept lying in warm carbolic lotion (1 in 80), 
may be cut up into pieces about the size of canary seed, and replaced on the 
surface of the membrane ; or the whole disc of bone may be replaced entire ; 
even, however, if the bone is not replaced, the gap is largely filled up by 
bone. In some cases, of course, it is desirable to have the aperture 
yielding, so that it may give way before increased intra-cranial pressure. 
Provision may be made for drainage, or the wound may be closed and dressed 
antiseptically in the ordinary fashion. After the operation the child is kept 
absolutely quiet in bed, and fed on weak animal broths and diluted milk in 
small quantities. If the case is doing well, there will be no need to disturb 
the dressings for a week or ten days, when the wound will be found healed, 
with the exception of the drain opening. Should no growth be found, or 
should there be very extensive encephalitis, or if the tumour lie too extensive 
for removal, the operation must be abandoned. Such are briefly the general 
rules to be adopted in dealing with brain tumours, and a large part o\ the 
description will also apply to operations tor cerebral abscess, or for those 
cortical lesions which give rise to epilepsy or other troubles and necessitate 



470 Diseases of the Nervous System 

surgical measures. A few additional remarks may be made on the two last- 
mentioned subjects. As to cerebral abscess, it is the result, apart from 
tuberculosis, most commonly of injury or disease of the ear ; in the case of 
traumatic abscess the seat of the abscess will usually, though not always, 
correspond with the seat of the external injury, though this guide should be, 
of course, supplemented by the indications given by any paralyses that may 
be present. The steps of the operation are those already described ; should, 
however, no evidence of the abscess be seen on exposing the brain, careful 
systematic exploration to a depth of from one to two inches should be made 
in ever}'' direction from the centre of the part exposed. This is best done 
with a grooved needle, fine trochar and canula, or director. Should pus be 
found, the opening must be enlarged and the abscess cavity drained, and the 
operation completed as above described. (For further details of cerebral 
abscess, the result of otitis, vide chapter on Diseases of the Ear.) 

Where trephining is done for Jacksonian epilepsy, it must be remembered 
that pressure or irritation may be due to a depressed or thickened portion of 
bone, to a local pachymeningitis, or to a cicatrix, or to local inflammation of 
the cortex of the brain itself. If the irritant is cranial, the offending bone 
must be removed. So also, if a local thickening of the dura mater is found, 
it should be excised. If, however, the lesion is in the brain itself, the ques- 
tion arises whether it is so extensive that removal of the injured part can be 
effected without an extent of paralysis following which would render the 
patient's condition worse than it already is. The details of the operation are 
the same as in the case of tumour or abscess. For further information we 
must refer to the papers of Dr. Macewen, Mr. Horsley, and others. There 
is no doubt that, on the one hand, the brains of children are more tolerant of 
operation than those of adults, and, on the other hand, that brain lesions 
which would prove fatal to adults are not only recovered from in children, 
but may. leave little or no permanent effects, even if left to nature. Each case 
must be judged on its merits. 

The dangers of hernia cerebri and diffuse encephalitis or meningitis are 
no doubt considerable, but with thorough antisepticism these risks may be 
generally avoided. It has been shown by Dr. Macewen that hernia cerebri, 
though it may result from imperfect wound management, may also be due to 
a pre-existing encephalitis, even in the absence of any septic condition of the 
wound. Should hernia cerebri appear, it is best dealt with by pressure 
applied over the wound by means of a plate of sheet-lead laid outside the 
inner layer of dressings. 

The subject of operative measures in disease and injur)' to the spi?iac 
cord is still more in its infancy than is that of cerebral surgery, and no definite 
rules can be laid down ; some account of the matter will be found, under the 
head of Spinal Caries and Spina bifida. 

It must be looked upon at present as a much more serious matter to open 
the spinal theca than to incise the dura mater ; hence greater hesitation 
should be felt in dealing with cases requiring so severe a measure. 

Cerebral Haemorrhage. 

We have already remarked (p. 18) that cerebral haemorrhage occurring 
in early life is hardly ever the result of a ruptured artery. Haemorrhage 



Cerebral Hcemorrhage 471 

does, however, not infrequently take place from the venous capillaries on the 
surface of the brain, and also, though in less degree, into the grey and white 
matter. The pia mater and its capillaries are exceedingly delicate in the 
infant, and when distended with hypervenous blood, as during some inter- 
ference to the respiration, they are exceedingly liable to rupture or to allow 
the blood to ooze through their walls. Hypervenous blood appears more 
readily to escape from the vessels by oozing than does ordinary blood. 
Meningeal bleedings of a larger or smaller amount are constantly found in 
infants who have been born asphyxiated, or who only survive their birth a few 
days in consequence of feeble respiratory powers (see fig. 4). The same con- 
dition is seen in infants who have been ' overlain in bed,' and in those who 
have died in convulsions. Clots of various sizes may also be found in the 
central white matter, in the internal capsule, and in the masses of grey matter 
at the base of the brain. The younger the infant the greater will be the 
brain damage done by the bleeding, as the brain is exceedingly soft at birth 
and easily injured ; the more immature the brain, the more is its develop- 
ment likely to be interfered with. As the result of the brain damage 
there may be hemiplegia, diplegia, paraplegia, or idiocy, with or without 
paralysis. The paralyses which date from cerebral haemorrhage at birth 
are mostly more severe than those which follow haemorrhages in older 
children. Cerebral haemorrhage apart from a meningeal bleeding, when it 
occurs during early life, takes place in ' bleeders,' and often as the result 
of a blow. 

Postpartum Meningeal Haemorrhage. Birth Palsy. — A delayed 
labour from any cause is liable to give rise to asphyxia, the vessels of the pia 
mater being gorged with dark venous blood, and a leakage takes place, the 
blood oozing from the distended vessels. The damage done by the pressure 
of the clot forming on the convex surface of the brain may be sufficient to 
permanently injure the cortical motor or other cortical centres. The newly 
born infant's brain is exceedingly soft and readily injured, as anyone knows 
who has attempted to remove one post-morteui without damage ; if the 
slightest injury is clone to the brain by the saw in dividing the skull, the 
brain substance will ooze out of the saw-cut almost like clotted cream. Now, 
not only may a considerable damage be done to the brain by a comparatively 
small surface haemorrhage, but as the cortical centres are imperfectly developed 
at birth, the pressure of a clot or a rupture of the grey matter may readily 
prevent growth and development. The consequences of this brain damage 
are various, but are often not very apparent for some months or more 
after birth. The mental powers may never properly develop, though 
the limbs are strong, and the child is mentally weak or an idiot ; or the 
lower extremities are stiff and weak, or there is a paresis of hemiplegic 
distribution, the child generally also being mentally deficient. In all a history 
of a prolonged labour, or of being 'born blue,' can be obtained. 

A whole family is often more or less affected when the mother has a 

narrow pelvis, or for various reasons has difficult labours ; some ot the 

infants may escape if born before they are fully developed. First -horns are 

apt to suffer the most, as can he readily understood. 

The following history of a family may form an illustration of the damage 

which maybe done by difficult labours. Mrs. Ct. has always difficult labours 



472 Diseases of the Nervous System 

in consequence of a narrow pelvis. She has had seven children born at or 
near full time. 

1. Willie, eight years old, suffers from spastic paraplegia and is mentally 
deficient (figs. 93 and 94). (An inmate of the Royal Albert Asylum.) 

2. John died at thirteen months of convulsions ; 'head never was right.' 

3. Clara, six years, is all right. 

4. Baby, died soon after birth. 

5. Baby, born dead. 

6. Boy, two years old, is all right. 

7. Girl, four months old ; both legs semi-rigid, exaggerated tendon 
reflexes, ankles rather stiff. 

In this family of seven, two appear to have escaped uninjured ; of the 
remaining five, two are living, having sustained a brain damage, and three 
are dead, their death no doubt being directly due to a birth-injury to the 
brain. 

Symptoms. — The most common symptom which immediately follows 
the meningeal haemorrhage is convulsions ; sometimes there is paralysis, 
and there may be rigidity. In the great majority of the cases there is no 
marked paralysis immediately following birth, or at any rate it escapes thc 
m other's attention, and it is only at the end of the first year that it is noticed 
there is stiffness about the child's legs, which prevents it from walking or 
from making any attempts to walk. Mostly, however, when the infant is a 
few months old, a careful examination of the lower extremities will reveal an 
exaggerated knee-reflex and a stiffness of the ankle joints. In some cases 
there is over-action of the adductors of the thighs, so that the legs are con- 
stantly crossed, with probably also more or less talipes equino-varus. Both 
arms may be affected, or an arm and leg only ; there is usually backwardness 
in talking. When the symptoms are fully developed, as they usually are at 
two or three years of age, the rigidity of the limbs, most frequently the legs, 
is very characteristic ; there is ' spastic paraplegia.' In a severe case the 
child cannot walk or stand unaided, and lies helplessly in bed ; the knees are 
semi-flexed, with adductor spasm, the tendo Achillis is drawn up, so that the 
foot is in a position of equino-varus, there is exaggerated knee-reflex, and 
ankle clonus. In some instances the child, though unable to stand or walk 
without help, on account of the talipes equinus present, can crawl, and may 
learn to do this fairly well ; this was the case with Willie G. (see fig. 93). This 
condition may remain throughout life, and occasionally adults belonging to 
this class may be seen crawling on all fours in the streets, and gaining their 
livelihood by begging. 

Many, perhaps the majority of cases, learn to walk in some sort of a 
fashion, but with difficulty, on account of the spasm of the gastrocnemii and 
the consequent tendency there is to fall forwards, and the awkwardness and 
want of control over their movements. The arms are more rarely affected 
than the legs ; sometimes there is slight rigidity in one only or in both, which 
interferes with their use, or the elbow is flexed, the wrist flexed and pronated, 
and the fingers flexed at the metacarpophalangeal joints. There may be 
present the irregular movements known as athetosis (see p. 477). Sometimes 
there is slight facial paralysis, only noticeable when the child laughs or cries ; 
^ye have never seen it well marked. 



Birth Palsy 



473 



The child is usually backward in talking, and in some cases where the 
mental defect is marked they never can utter anything but meaningless 
sounds. The mental condition varies ; sometimes there is complete idiocy, 
more often some loss of intelligence, or the child is emotional, being easily 
roused to anger, and, if going to school, is teased and tormented by its com- 



panions. The shape of the head is often unaltered 
small and more or less flattened in the parietal regions. 



occasionally, it is 








Fig. 93.- -Spastic Paralysis, the result of 
Meningeal Haemorrhage at Birth. Willie 
G., aged 8 years. The weight of the hody 
is partly supported hy heing held up by the 
arms, partly by resting en the toes. 




'^^y m& 



Fig. 94. — Willie G., after division of the 
tendo Achillis and forced dorso-flexion. 



Cerebral Haemorrhage occurring: alter Birth. Acute Cerebral 
Palsy.- — Cerebral haemorrhage may occur from various causes besides those 
in operation during the act of birth. Blood may ooze on to the surface of 
the brain or into the white or grey matter during over-distension ot the 
cerebral veins from any cause. The commonest cause is a series o( con- 
vulsions. Haemorrhage may occur, however, during whooping cough, or in 
severe vomiting, or in any cases in which there is a severe venous congestion 
of the brain. We have several times seen/ ( ^7 mortem .1 meningeal bleeding 



474 Diseases of the Nervous System 

in infants who have died in convulsions, and also after whooping cough. 
Such haemorrhages are most common during the first two years of life — in- 
deed, they are uncommon at any other period, and this is to be expected 
when we remember how much more delicate the capillaries and cerebral veins 
are during infancy than in later life. 

The convulsions which immediately precede the haemorrhage may be 
the result of many different conditions. Sometimes the primary illness is 
measles, acute diarrhoea, pneumonia, whooping cough, or scarlet fever ; more 
often, perhaps, the attack cannot be referred to any one of these, and the 
principal symptoms are high fever and drowsiness, and then the convulsions 
supervene ; then, after a series of convulsions, a more or less well-marked 
hemiplegia is noted. Such cases are often looked upon as 'brain fever' or 
' congestion of the brain.' In some cases there is a history of a fall. In other 
cases the convulsions are undoubtedly reflex, especially from colic. A high 
temperature, 105 to 106 , seems to excite convulsions. 

In all cases we have noted the convulsions were severe, often one-sided 
at first, but tending to become general ; they may last from a few hours to a 
week ; the infant may remain a long time in a state of coma. Probably a 
small amount of bleeding may take place without producing any symptoms, 
and absorption takes place and no ill effect remains. In others there may 
be a slight and transient paresis of an arm or leg or both, such as is sometimes 
seen after an epileptic fit. In another class no paralysis is left, but the child 
grows up with feeble mental powers which date from the time of the con- 
vulsions. In a common class of case a more or less complete hemiplegia or 
diplegia is left, with perhaps more or less facial paralysis. 

As an instance of reflex convulsions giving rise to cerebral haemorrhage 
we may relate the following case : 

Convulsions ; Cerebral Haemorrhage. — George L. , aged 12 years was brought to the 
Children's Hospital, Manchester, suffering from tuberculosis and also hemiplegia ; his 
mother gave the following history. He was strong and healthy when born, though the 
labour was somewhat tedious. There was no history of hereditary syphilis. He walked 
at twelve months of age, and was well and strong till two years of age. At this time he 
had a fit, which was attributed to his eating some crust of apple pie some half an hour 
before the attack. He was playing on the doorstep at the time, he suddenly became 
' black about the mouth,' and would have fallen but for another boy who caught him in 
his arms. The fit, including the unconscious state which followed, lasted about ten 
minutes. Two weeks after he had another fit, which lasted half an hour, and was more 
severe than the first ; his right arm and leg were especially convulsed. After this fit it was 
found that his right arm hung useless, and in trying to walk he dragged the right leg. 
The face was unaffected. The arm was always worse than the leg ; at first he could not 
hold anything in it. Both arm and leg slowly improved, but have remained more or less 
stiff and rigid. Ever since the first convulsion he has been subject to fits, but he has 
not had any for the last two years. He has had on an average two fits a week, 
from two years of age till he was ten years. They only lasted some minutes, accom- 
panied by loss of consciousness ; he always knew when a fit was coming by his right 
thumb beginning to ' work.' He used to say, ' Mother, my thumb's working ; ' then he 
would fall over almost immediately if not caught. The fits were mostly right-sided, but 
the left arm and leg would also ' work. ' Lately he has used his right arm more than 
formerly, being able to hold things in it. 

When examined (September 8, 1890) it was evident he was affected with an old 
hemiplegia : he could walk, but dragged his right leg after him. He could use his right 
arm for holding things, but could not feedhimself with it ; the shoulder joint was fairly 



Cerebral HcemorrJiage 



47 S 



movable, the elbow bent and semi-rigid, and the hand pronated ; the stiffness could be 
overcome by slight force. The right leg was somewhat stiff at the knee and slightly 
flexed as he lay in bed, with the foot pointed. There was exaggerated knee reflex on the 
right side. There was no evidence of any mental weakness. 

He died of tuberculosis in February 1891. The post-mortem was made by Mr. R. O. 
Bowman, senior resident medical officer at the Children's Hospital ; we examined the 
brain next day. An examination of the outer surface of the brain showed it to be per- 
fectly normal, the membranes were healthy, there was no flattening of the convolutions or 
any evidence of an old surface haemorrhage. The internal parts were examined by making 
transverse sections. The first section taken through the centrum ovale showed nothing 
abnormal. A section made exposing the lateral ventricles, without slicing the corpus 
striatum, showed an old cyst (fig. 95, a) with brownish contents, § inch in length, 




Fig. 95.— Horizontal Section of Brain, exposing lateral ventricles (x I), fr, fissure of 
Rolando ; a, old blood cyst ; b, n, B, B, small blood cysts. Haemorrhage at two years 
of age ; death at twelve years of age. 



situated on the left side in the white substance between the fissure of Rolando and the 
corpus striatum ; and four small cysts B B situated on the right side in the white substance. 
The cyst marked a was apparently about \ inch in depth. There was no sclerosis or 
induration in the neighbourhood of the cysts. A third section made lower than the above, 
and on a level with the upper surface of the cerebellum, and slicing the optic thalamus, 
caudate nucleus, and internal capsule (tig. 96), showed the lower limit of the cyst seen in 
fig. 95, a second old blood-cyst 1;, and another small one at C. Another similar cyst was 
found in the white substance of the frontal region at a lower level than ng. 00. 

Sections of the cord made in the cervical, dorsal, ami lumbar regions did not show- 
any sclerosis or wasting of the descending tracts; neither was there an) wasting of the 
internal capsule or crura. 



476 



Diseases of the Nervous Syste, 



In reviewing the history of the case, in the light of the morbid anatomy, 
there is much reason to believe that a multiple haemorrhage took place when 
the boy was two years of age, and that one or more (a, fig. 95) of the 
haemorrhages gave rise to the paralysis by the destruction of some of the 
white fibres en route from the motor- surface centres to the internal capsule. 
There seems to be little room for doubt that the initial convulsions were the 
cause and not the consequence of the multiple haemorrhages. It is hardly 
conceivable that the multiple haemorrhages should be caused by any throm- 
bosis, embolism, or arteritis ; they must presumably have been due to a 




Fig. 96. — Horizontal Section through Brain at a lower level than fig. 95, showing Optic 
Thalamus and Caudate Nucleus ( x -?). a, b, c, old blocd cysts. 

sudden engorgement of the veins due to asphyxia, such as takes place in a 
fit in consequence of spasm of the respiratory muscles. 

As an example of a hemiplegia following convulsions associated with 
measles the following case occurring in a healthy boy of twenty months, a 
patient of Mr. Wilson of Cheadle, which came under our observation, may 
be taken as an example. Mr. Wilson's notes are as follow : 

Measles; Pneumonia ; Convulsions,' Hemiplegia. — Boy, twenty months. The measles 
rash was first noticed on May 10 ; convulsions commenced at noon on the nth : these 
consisted of clonic spasms of the left arm and leg and right side of the face ; the eyes 
were turned to the right side and fixed ; the pupils were dilated, the temperature rose to 
105 , the pulse was too fast to be counted ; the convulsions continued during the morning ; 
at t p.m. the temperature was 107° F., when the patient was put into a cold bath ; it was 
again 107° at 4 P.M., when he was bathed again and five grains of quinine given by the 
rectum ; at this time an examination of the lungs showed pneumonia at one base ; at 6 P.M. 
the temperature was 103°, and the mother noticed he had lost the use of his left side ; at 



Cerebral Haemorrhage 477- 

8 p.m. it was noticed that the left arm was completely flaccid, paralysed, and apparently 
anaesthetic ; the leg was rigid, but on tickling the sole of the foot the toes moved slightly. 
Pneumonia developed the next day ; the child died on the 13th, the arm and leg remaining 
in the same condition; unfortunately, no autopsy could be obtained. The paralysis was 
probably due to a surface bleeding following the convulsions. 

The following case may be given as illustrative of one which recovered 
from the immediate effects of the acute attack : 

Convulsions ; Hemiplegia. — A child of thirteen months, who was cutting her lateral 
incisor teeth, was suddenly seized with vomiting, diarrhoea, and high fever ; then a series of 
convulsions came on which lasted eight hours, the right side working most ; at the end of 
this time it was noticed she had completely lost the use of the right arm and leg, and the 
face was drawn. Her speech was affected, so that she could not say any of the words 
she had learnt. For more than a month she lay quite helpless. Seven months afterwards, 
when twenty months old, she could not walk or rest her weight on the right leg ; the arm 
was bent at the elbow, the hand clenched, but the facial paralysis had disappeared ; she 
could say a few words, but was backward in intelligence. At the age of four years she 
had much improved : she could walk quite well, having apparently regained power in her 
leg, though there was slight equino-varus, but the right arm remained stiff and weak, the 
elbow flexed, the wrist bent and pronated, and the fingers clenched. The fingers closed 
spasmodically, so that she was in the habit of placing things with her left hand between 
the fingers of her right, where they were held without effort. She could talk and was very 
intelligent. 

These cases may be taken as types of acute cerebral paralysis due to 
cerebral haemorrhage ; the symptoms in such may be varied, but they all 
three agree in that convulsions were present and the paralysis set in sud- 
denly and unexpectedly, as a surprise to the attendants. In the second and 
third there was high fever. 

For the succeeding few weeks, if the patient survives, he remains helpless, 
though the condition gradually improves ; if there is anaesthesia, this passes 
away ; the aphasia, if present, disappears ; the face improves, and still later 
more or less power returns in the muscles of the legs. The arm remains in 
part permanently paralysed, and in the course of some months contractures 
come on ; the greatest improvement takes place in the muscles about the 
shoulder ; the elbow is flexed, the wrist flexed and in a position of pronation, 
the fingers are bent up, inclosing the thumb. The amount of paresis and 
contracture varies considerably, according to the severity of the case. 
Peculiar movements often occur in the paralysed limbs, more especiallv in 
the hands, a condition to which the term ' athetosis ' has been applied. The 
movements as a rule are quite unlike chorea ; they are slow, consisting in alter- 
nate contraction of opposing muscles, giving rise to irregular movements o( 
the fingers and hand; they are involuntary, and take place in muscles in 
which there is ordinarily a certain amount of tonic spasm. The term ' mobile 
spasm' has been applied to this condition by Cowers. As the latter author 
points out, the interossei and lumbricales muscles (which flexthe metacarpo- 
phalangeal and extend the phalangeal joints) are mostly affected ; less often 
the long extensor, and never the long flexor of the fingers. 

In consequence, the hand is apt to assume the interosseal position. The 
movements may take place independently in the interossei, so that one or 
more fingers may be extended at a time, or .ill the lingers may be extended 
and separated, and the slow irregular movements ot the extended fingers 
suggest the movements of the tentacles oi a cuttle-fish (Gowers), The 



47 8 Diseases of the Nervous System 

movements are involuntary, but are made worse by attempts at voluntary 
movements. 

The paralysed arm is apt to grow more slowly than its fellow, so that it is 
shorter and smaller, and often blue and cold. The leg, following the usual 
course in hemiplegias, recovers more quickly and perfectly than the arm ; 
there is more or less equino-varus, and there may be some shortening, but 
the child can get about fairly well. 

The intelligence often remains impaired'; sometimes there is complete 
idiocy, more often only impaired mental powers or backwardness. Epilepsy 
is also common. 

Morbid Anatomy. — If an opportunity occur of examining the brain shortly 
after the occurrence of the haemorrhage, blood varying in amount from a 
punctiform haemorrhage to a large clot or clots will be found beneath the pia, 
situated most commonly at the vertex, but also at times at the base ; it is 
usually double, but mostly more extensive on one side than the other. Blood 
clots may also be found in the central white matter, or in or about the masses 
of grey substance at the base. There may be actual destruction of brain 
substance as a result of the bleeding, and probably in most cases softening- 
follows. 

If death occurs after some years, atrophic changes of varying amount will 
be found, or there may be old blood cysts, if the bleeding took place into the 
brain tissue. In cases in which there has been a hemiplegia or diplegia, 
the atrophic changes are situated in the motor area. The dura mater maybe 
adherent and the pia mater thickened over this area, and instead of fully 
developed convolutions in the ascending frontal and parietal regions a 
scarring or cicatrisation has taken place, no doubt as a result of the softening 
taking place after the haemorrhage. This was the case in the brain of a boy 
recently under the care of our colleague Dr. H. R. Hutton (see fig. 97), and 
also in a case recently shown by Dr. T. R. Railton at the Manchester Patho- 
logical Society. 1 

In Dr. Hutton's case the skull was thickened and flattened over both 
parietal regions, there was spastic diplegia, the infant was an idiot. At the 
post-mortem the dura mater was found to be adherent to the skull, the pia 
thickened over the motor area and adherent, a well-marked depression or 
sulcus being present over both motor areas. In some cases atrophy of the 
frontal or occipital lobes has been found as a result of the old haemorrhage. 

Treatment. — In connection with the treatment of ftost-partum cerebral 
haemorrhage, the most important matter is to prevent its occurrence by so 
expediting labour, that the infant does not suffer from asphyxia. Much may 
be done to prevent, very little can be done to cure. We are powerless — as 
far, at any rate, as drugs are concerned— to remove a cerebral clot or undo a 
brain damage. Hence the question of immediate trephining to remove the 
blood deserves consideration, and will probably be in the future a recognised 
mode of treatment in cases where the haemorrhage is local and superficial. 
In those cases in which the bleeding is secondary to convulsions, the most 
important matter is to prevent any further return of the convulsions ; to this 
end the bromides and chloral must be used with a very free hand, and pushed 
so as to render the infant drowsy. Ice should be applied to the head, and 
1 See Medical Chronicle, March 1892, p. 429. 



Cerebral Hemorrhage 479 

the head and shoulders kept well raised. A moderate purge should be given, 
sufficiently large to act freely on the bowels ; a piece of mustard leaf may be 
applied to the back of the neck if the child is unconscious, care being taken 
not to leave it on long enough to produce a sore. The drugs most likely to 
be of service are small doses of digitalis, to steady and increase the power of 
the heart, and bromide in full doses if there is any tendency to convulsions. 
The paralysed limbs should be wrapped in cotton wool. As the patient is 
recovering from the effects of the attacks, nux vomica, iron, and syrup of the 
hypophosphites may be given. In the later stages, when contractures are 
setting in, massage should be diligently and intelligently employed ; but the 
patient's friends must be warned that a cure is not likely to be effected by 




Fig. 97. — Brain from a boy aged 18 month?, showing, a, depression over both motor areas, due 
to meningeal haemorrhage at birth; Bj cerebellum only partially covered by the occipital 
lobes. The patient had a typical diplegia. (Dr. H. R. Hutton's case.) 

any form of treatment, and that rubbing, as also galvanism, is only palliative. 
Every effort should be made to bring out the patient's voluntary power. The 
deformities resulting may be improved by division of tendons and the appli- 
cation of splints. 1 

With regard to prognosis, it is well to give a carefully guarded opinion 
as to the future. Nearly all cases improve, and slight paralyses get quite 
well. Severe cases improve as years go on, but it is doubtful if they ever 
•completely recover. In the majority of cases there is some mental feeble- 
ness, either a mere backwardness, or there may be decided idiocy. Some 
cases become epileptic. 

Medullary Haemorrhage. — In speaking o\ haemophilia ami of the 
1 Vide Willard, Trans, American Orthop, Assoc, September 1S01. 



480 Diseases of the Nervous System 

h hemorrhagic diathesis we have mentioned the fact that a cerebral haemor- 
rhage may occur in these conditions after a slight head injury. We have 
related such a case (p. 370), and referred to some cases related by Steffen. 
The following case is a rare one belonging to the same category. 

Hcsmophilia ; Medullary Hemorrhage. — Norah M. , aged 3 years 10 months. Family 
history good. Father two years before suddenly lost the hearing in one ear, which was 
supposed to be due to haemorrhage. Patient had a sharp attack of scarlet fever, followed 
by glandular abscesses eighteen months ago. For the last year it had been noticed that 
she had exhibited a tendency to 'bruise,' purple spots appearing on the skin after the 
slightest injuries. She was a well-nourished child, but had always been difficult to feed. 
She was quite well till the morning of December 22, when she vomited and retched several 
times ; there was no history of a blow, but she had been to a children's party the evening 
before and had romped a good deal. The following day she was seen with Dr. Lawton ; it 
was then noted she could not stand or sit, and when held up her head fell to the right side. 

There was slight paralysis of the left side 
^jjjjl^. of " tne ^ ace ' including the orbicularis, but 

-^J^" -vr. c the eye could be closed ; the voice was weak 

and had a nasal twang ; on attempting to 
swallow, she coughed and spluttered as if 
some of the fluid entered the larynx. There 
was no cardiac murmur. Temperature. g8 c . 
December 24. — She had recovered some 
power in her legs, and she could sit up, but 
her head still fell over to the right side. It was 
noticed that her breathing was peculiar, the 
right side of the chest was moving excessivel v. 




Fie. 99- — Transverse section of medulla 

through middle of olivary bod}- showing 

laminated clot, compressing the right 

olivary nucleus, root of vagus, and nerve 

Fig. 98.— Posterior aspect of medulla showing centres in floor of fourth ventricle. _ 

discoloration over clot (nat. size). v. vagus. 11, hypoglossal (nat. size). 

while the left side was hardly moving at all ; rales were heard on both sides. December 25. 
The swallowing was better, but it was clear the lungs were getting choked, as the rales were 
heard freely all over, the right side still moving more freely than left. Temperature io2 : . 
The child became more and more dusky, the respirations increasing in number ; there was 
intense restlessness, and finally death from asphyxia on the evening of December 26. 
Post-mortem (head only). — No cerebral haemorrhage except in the medulla, where it was 
noted that the right side of the medulla was swollen and discoloured (see fig. 98). On 
transverse section (after hardening) through the middle of the olivary bodies, a round lami- 
nated clot £ inch in diameter was found, which had compressed the root of the right vagus, 
olivary nucleus, and also the nuclei in the lower part of the floor of the fourth ventricle 
(see fig. 99). 

We are indebted to Dr. R. T. Williamson fcr microscopical examination of the clot. 
He found no evidence of any aneurismal sac. 

Embolism.— Among the various causes producing a paralysis of hemi- 
plegic distribution we must mention embolism. Embolism chiefly occurs in 
patients suffering from endocarditis, but also it appears to occur at times 



Embolism of the Brain 



481 



when there is no form of heart disease present, the thrombus appearing to form 
in the left auricle, or pulmonary veins. Embolism is perhaps most common 
in acute or malignant endocarditis; this was so in the case recorded on 
page 338 (see fig. 100). 

In the following case there was hemiplegia in consequence of a blocking 
of the middle cerebral artery, either from embolism or thrombosis : 

A boy of one year old, who had suffered since birth from marked cyanosis due to 
obstructive pulmonary disease (fig. 52 represents the heart of this case) and constant 
dyspepsia, was seized one night with vomiting and convulsions, followed by paralysis of 
the left arm and leg. When seen on the following morning, the head and neck were 
turned to the right side, the eyes were suffused and blinking, as if some foreign body was 
present, the right pupil was smaller than the left, but both acted to light ; the child was 
apparently quite blind ; there were no retinal haemorrhages, and the optic discs were 




L < JVV>LV 



Fig. 100.— Horizontal Section of a Brain, showing patch of softening involving the left lenticular 
nucleus and anterior limb of the internal capsule. The lenticular-striate artery was plugged 
with an embolus and impervious. There was complete hemiplegia of the right side. (See p. 338.) 



normal. The face was drawn to the right side; there was complete loss of power, and 
apparently loss of sensation, in both arm and leg o( the left side ; no cry could be elicited 
on pinching or pricking the skin of either limb. The child was drowsy, but not uncon- 
scious, as he appeared at times to know his mother when in her lap. He was 
apparently deaf for the first twenty-four hours, though there was necessarih some diffi- 
culty in ascertaining this; by the next day, though remaining blind, he knew the voices 
of his friends, an 1 turned towards the direction of their voices : it was clear, also, thai he 
heard with both ears. Within a fortnight sight had returned, so that he co-aid re 
his mother and his toys. His friends thought he rega ned his sight first in 
By the en i of six weeks seas ition had returned, as far as could be ju Iged, in the ai m and 

leg, and some power was returning, as he m wed both limbs of the left - d \ \ week or 

1 1 



482 



Diseases of the Nervous System 



two later he could hold a rattle in the left hand, but not raise it to his mouth ; the leg 
showed a tendency to draw up, and the knee reflex .was much exaggerated. The child 
was quite intelligent and bright. Before death (seven months after seizure) much improve- 
ment had taken place : the child could put out his hand, but there was some rigidity both 
in the arm and leg. The child died of bronchitis. Post-mortem. — On removing the 
brain, it was evident the right hemisphere had shrunk, being slightly smaller than the left, 
and that there was a large cyst (porencephalus), containing clear fluid, occupying the 
central part of the convexity of the right hemisphere (see fig. 101) ; the cyst corresponded 
with the distribution of the middle cerebral artery, excepting the branch to the inferior 
frontal convolution. The middle cerebral artery beyond its first branch was impervious, 
and contained old clot. It was quite clear in this case that there had been thrombosis or 
embolism of the middle cerebral, with a subsequent softening of the area supplied by it \ 
a horizontal section showed that the internal capsule had been compressed. 

No emboli were found elsewhere ; there was no endocarditis of the mitral 
or aortic valves, but a much contracted pulmonary artery and open foramen 
ovale. 




Fig. 101. — Cyst formed by softening of brain substance, secondary to obstruction of the middle 
cerebral artery beyond the first branch (to inferior frontal convolution). The cyst wall has 
fallen in from escape of its contents. Child nineteen months old ; death seven months after 
onset of paralysis. 

Dr. F. Taylor records a typical case of embolism following endocarditis : 

A boy of five years, two weeks after an attack of scarlet fever, was seized with hemi- 
plegia of the right side ; the urine was albuminous. Death occurred from diphtheria 
nine weeks afterwards ; embolism of the left middle cerebral artery, with extensive soften- 
ing of the left hemisphere, was found. There was endocarditis of the mitral valve. 

Abercrombie reports a case of a boy aged six years who was under treat- 
ment for diphtheria, and who on the fifteenth day was seized with general 
convulsions and left hemiplegia ; he died eleven days later. The middle 
cerebral artery was found plugged with an embolus ; infarcts were also found 
in the spleen and kidneys. There was no heart disease, and it was difficult 
to understand the source of the emboli, unless formed in the cavity of the 
heart or in the pulmonary veins ; this might be possible in paresis of the 
respiratory muscles and disturbed innervation of the heart, following 
diphtheria. 

Dr. Trevelyan reports a similar case to Dr. F. Taylor's, in a girl aged 
eight years convalescent from diphtheria. 



Thrombosis 483 

A sudden hemiplegia may be caused by meningitis, the immediate cause 
being softening following thrombosis or embolism of the vessels ; the 
meningitis is usually tubercular. Thus a boy of six months of age, who had 
been apparently healthy, suffered for a week or two from febrile disturbance, 
dyspepsia, and irritability, attributed not unnaturally by his friends to 
'teething : ' one evening at 8 P.M. he was convulsed, the right arm and leg 
twitching most : this was followed by right hemiplegia, including the face. At 
3 A.M., when seen, the infant was unconscious, with contracted pupils, Cheyne- 
Stokes respiration, the face drawn to the left, the right arm and leg com- 
pletely powerless. Death took place three days later, the temperature rising 
in the meantime to 105 . The post-mortem showed a basal meningitis 
(tubercular), much fluid in the lateral ventricles, and softening of the left 
hemisphere and corpus striatum. 

Another lesion (this a rare one) giving rise to hemiplegia is an aneurism 
of the middle cerebral artery, the result of embolism, in cases of acute 
endocarditis ; this was the case in a girl of nine years under our care who 
suffered from intermittent pyrexia and albuminuria, and in whom a loud 
systolic murmur was present. To these symptoms was added acute pain in 
the frontal region, coming on suddenly. An ophthalmoscopic examination 
showed large retinal haemorrhages surrounding the disc. A week later there 
was paresis of the right arm, no paralysis, but exaggerated tendon reflex of 
the right leg. Six weeks later she fell back unconscious while sitting up in 
bed : there was now right facial paralysis, and paralysis of the right leg. 
Death followed ten days later. An aneurism the size of a small walnut, 
on the second branch (to the ascending frontal convolution), near its origin 
from the trunk of the left middle cerebral artery, which had ruptured and 
given rise to meningeal haemorrhage, was found post mortem. 

Thrombosis of the Cerebral Sinuses and Veins. — Thrombosis of the 
cerebral sinuses or veins is not a common occurrence during infancy and 
childhood. It may occur in the superior longitudinal, lateral, or cavernous 
sinus. It is most likely to occur in extreme anaemia, after exhausting 
diseases as acute diarrhoea, where the force of the heart is weakened and a 
stasis or slowing of the venous current takes place. Thrombosis may also 
occur in the surface veins under similar circumstances, or the clotting in the 
veins may be the result of meningitis. The immediate result of the obstruc- 
tion to the veins or sinuses is to distend the venous branches behind the 
obstruction to their utmost capacity, and possibly also to give rise to puncti- 
form haemorrhage and softening of the brain. Thrombosis of venous 
channels may take place in the neighbourhood of some inflammation, as in 
otitis, and pyaemia may result. 

Symptoms. — There is a condition of great exhaustion and pallor, and 10 
these are added cerebral symptoms and venous obstruction. The fontanelle 
is tense, the veins of the forehead, nose, and face are distended : there is 
epistaxis and probably convulsions ; perhaps, also, rigidity and retraction o[ 
the neck, and paralysis of one or more extremities. In making a diagnos s, 
it must be remembered that the so-called c false-hydrocephaloid ' or cerebral 
anaemia gives rise to convulsions, stupor, and coma, and is infinite 
common than thrombosis. We are only justified in diagnosing the latter 
when there is distension o( the veins oi the face and forehead, or some 

• 






484 Diseases of the Nervous System 

definite paralysis. Thrombosis of the cavernous sinus is most likely to occur 
in some local lesion, as a tumour, as a periosteal sarcoma of the sphenoid 
bone, or caries ; the eyeball is prominent, there is oedema of the eyelids and 
distension of the veins of the forehead. 

Treatment. — The action of the heart must be strengthened by stimulants 
and digitalis, and the tendency to exhaustion and syncope must be combated 
by beef tea and highly concentrated forms of nourishment. The patient 
should be kept in the prone position as much as possible, with the shoulders 
and head raised. The prognosis is necessarily extremely grave. 

Arteritis. Softening-. — An acute arteritis in rare instances occurs in 
infants a few months old who are the subjects of congenital syphilis. Such 
cases have been recorded by Dr. T. Barlow, Chiari, and Heubner. Arteritis 
also occurs in syphilitic infants of all ages, accompanied in some cases by 
pachymeningitis and sclerosis of the brain. 1 

In infants, the principal symptoms are convulsions, in the form of 
muscular twitchings of an arm or leg, followed by paresis and contractures. 
The infant gradually becomes idiotic. The chief changes are in the arteries 
as described by Heubner : there is a thickening of the internal coat, the 
nuclei between the endothelium and the fenestrated membrane becoming 
increased in number, to be followed by fatty changes ; thrombosis takes 
place at the seat of the inflammatory changes. Softening of the brain 
follows over the area supplied by the blocked arteries. The following case 
illustrates this. 

Syphilitic Arteritis. Softening. — Infant first seen at three months of age, when suffer- 
ing from coryza and a well-marked rash. A month later the epiphyses of the lower end 
of the tibia and fibula, also the lower ends of the radius and ulna, were swollen and tender 
(fig. 86 was drawn from this case). When seven months old he began to suffer from con- 
vulsions, mostly left-sided at first, later the convulsive movements became general. In the 
course of a few months the left arm and leg, which were more or less paralysed, began to 
draw up and become more or less rigid ; the elbow was bent at right angles, the arm pro- 
nated, and the fingers flexed ; still later the right arm became similarly affected ; the child 
gradually became idiotic, and died at four months old. It was under mercurial treatment 
from three months of age. At the -post-mortem the arachnoid was of a milky colour, and 
there was an excess of subarachnoid fluid ; there was no effused lymph or meningitis. 
The superficial layer of the grey matter on the convex surface of both hemispheres, 
especially the right, was softened and could be readily scraped away ; the superficial 
layer of the caudate nucleus and optic thalamus were in the same condition of softening. 
Microscopically, the grey matter showed extensive fatty degeneration ; the minute arteries 
were extensively blocked with old thrombi, their inner coats being thickened and their 
nuclei increased in number. The large arteries were normal, as far as could be made out. 
There seems to have been an extensive syphilitic arteritis of the small meningo-encephalic 
arteries, thrombosis, and secondary softening of the superficial grey matter. 



1 J. S. Bury, M.D., Brain, April ii 



4 8 5 



CHAPTER XXI 

DISEASES OF THE NERVOUS SYSTEM — Continued 

Chorea 

CHOREA is a disease which occurs chiefly in children between the ages of 
six and fifteen years, and is characterised by irregular spasms of the volun- 
tary muscles, and in some cases by paresis of the extremities and mental 
weakness. 

Aetiology. — Chorea can hardly be said to be hereditary, but undoubtedly 
a tendency to neuroses or ' weak nerves ' runs in families, and instances 
might be adduced of emotional parents having children who suffer from 
chorea ; moreover, it is a common experience to find several sisters or brothers 
suffering from chorea, or perhaps one or more are neurotic or hysterical. 

Chorea is not common before the age of six years, and after the age of 
fifteen years the liability to attacks becomes very much less. It is more 
common in girls than boys, in this respect resembling hysteria and other 
emotional diseases. Analysing 633 cases which have attended at the Chil- 
dren's Hospital, we find that 454 were girls, and 179 were boys, giving a 
proportion of five girls to two boys ; these figures closely correspond to the 
statistics collected by other writers. 1 In 252 cases the ages of the patients 
were analysed, giving the following result : 

Under six years . . . . 15= 3 boys and 12 girls 

Between six and ten years . . 102 = 35 boys and 67 girls 
Between ten and fifteen years . 135 = 44 boys and 91 girls 

The youngest child was a girl of four years of age. 

The children most apt to suffer are the nervous and excitable, those who 
are easily frightened, especially if they are suffering from ill-health, the result 
of unfavourable life-conditions or rapid growth. 

By far the commonest exciting cause is a fright ; in 3S cases out o\ 2^2 
there was a definite history of the patient being frightened, the symptoms 
following in some cases next day, in others within a few days or a week. 
The causes of the fright were various : in one case, that of a boy, the symptoms 
followed three days after seeing a 'man with his throat cut :' sometimes the 
attack was ascribed to a k dog having flown at the child,* or the patient 
was 'frightened by a policeman,' or the child had been caned b) the school- 
mistress, or had had a fall downstairs. In such histories there is often some- 
thing it is necessary to discount : probably the scoldings at school were the 

1 See Fagge's Principles .;>.-</ Practice of Medicine, edited by Pye-Smith and 



486 Diseases of the Nervous System 

consequence and not the cause of the chorea ; but, on the other hand, it is 
certain that chorea may follow within a few hours of a serious shock to the 
nervous system. 

Mental strain, as working hard for an examination, in some cases appears 
to excite an attack ; this has occurred too often in our experience to be 
attributed to any mere coincidence. Given a fast-growing and delicate girl, 
of excitable disposition and not too well fed, who is at school for many hours 
during the day, and has to divide her attention between home lessons and 
various domestic duties, so that she becomes little else than a drudge, it can 
hardly be surprising that she suffers from a nervous breakdown. ' School- 
made chorea,' as Dr. Sturges calls it, is not by any means confined to the 
poorer classes, and, although among the better-to-do classes there is no ques- 
tion of poor food and household drudgery, yet there is often much forcing 
exercised to induce a girl, of perhaps delicate health, to keep pace with or 
run ahead of her stronger and more robust class-mates. 

In some instances children who are convalescent from various depressing 
diseases, such as acute rheumatism, enteric fever, or scarlet fever, are attacked 
with chorea. Rheumatism excepted, enteric fever in our experience more 
often than any other disease predisposes to chorea ; other nervous dis- 
orders, such as dementia, mania, and aphasia, are not uncommon after enteric, 
and are no doubt due, as is also the chorea, to the anaemia and exhaustion 
caused by the long drain on the system during the disease. For the con- 
nection of rheumatism with chorea, see p. 489. 

Heart disease in some instances precedes the attack of chorea, or, in other 
words, chorea makes its appearance in children suffering from cardiac disease. 

It sometimes happens that a source of irritation in some part of the body is 
the exciting cause of an attack of chorea ; thus we have seen a temporary 
chorea occasioned by suppuration in the middle ear, the choreic movements 
ceasing when the discharge made its appearance. In other cases it happens 
that chorea is an early symptom in pericarditis— this we have also seen ; in 
one case, in a little girl of four years, choreic movements preceded by a few 
days the physical signs of a pericarditis which proved fatal. We cannot help 
thinking that in such a case the chorea was symptomatic of the pericarditis, 
the latter being the primary lesion, rather than that the heart lesion was 
secondary to the chorea. 

Imitation in some cases seems to be a factor in the production of chorea. 
On one occasion five cases occurred in a girls' school immediately after the 
admission of a child suffering from chorea ; in such cases, perhaps, it may 
not be imitation so much as fright at seeing others affected, as Gowers 
suggests. We have never known children in the same ward to become 
choreic in consequence of a bad case being admitted, but we have seen 
cases of chorea apparently made worse by association with a bad case. 

Symptoms. — Most of those who suffer from chorea are in some way or 
other weakly, or at least not in robust health ; they are often anaemic, rapidly 
growing girls. Not infrequently, it occurs in girls who have gone out to 
service, and who are undertaking work which is beyond their strength. Often 
the first symptoms are a loss of control over the muscles, especially the 
flexors and extensors of the fingers and wrists, and a want of precision in 
the movements of the hands. The patient drops cups and saucers on the floor, 



CJwrea 487 

is unable to do needlework, fumbles sadly when she attempts to tie a piece 
of string, or spills her food when she passes it to her mouth. Sometimes, 
especially in younger children, the first thing noticed is that she 'makes 
faces,' her mouth screwing up so as to make grotesque grimaces, while she 
fidgets with her fingers, and when she attempts to dress herself makes use- 
less, clumsy, ineffectual movements. All this may go on for many days, 
perhaps weeks, without the friends thinking the child is really ill, and perhaps 
she gets scolded, both at home and at school, for her clumsy ways and in- 
attention to her .work. It is needless to say the scoldings do no good. Sooner 
or later the movements become too obvious to escape attention ; indeed, it 
is apparent to everyone that something is wrong. These movements, as 
Dr. Sturges points out, are much more vigorous in the upper part of the body 
than the lower, the hands suffering most of all. The fingers are opened and 
shut, the extensor and flexor muscles being constantly worked ; the arm is 
passed behind the back, then brought to the front ; if asked to shake hands, 
it is thrust rapidly forward, being directed with difficulty to the hand to be 
grasped. The tongue is protruded with a jerk, and perhaps drawn back 
again in a moment with a quick movement. The muscles of the face are 
frequently spasmodically contracted, so that queer grinning grimaces are 
constantly being made. The muscles of the neck are frequently contracted 
and relaxed, so that the head is moved from side to side or rotated. When 
the child walks, the feet join in the spasmodic movements, so that the gait 
is altered, the legs being thrown forward quickly, or if the patient stands the 
feet are restless, being shifted about from place to place. When the patient 
is at rest in bed she will lie still if not disturbed, but directly she is interfered 
with — as, for instance, to examine the chest — the movements begin, the hands, 
face, and trunk muscles being thrown into a state of clonic spasm. The 
muscles of respiration do not escape : the child takes a deep sighing inspira- 
tion, then perhaps there is a series of shallow irregular respirations. The 
irregular respirations may affect the pulse, so that it is irregular and inter- 
mittent. The movements cease during sleep, though sleep is not readily 
obtained ; indeed, in the worst cases the patient only sleeps when under the 
influence of chloral or opium, which has to be freely given in order to secure 
rest. In the milder cases the movement may be confined to one side ; this, 
however, is never the case when the -movements are severe, though it is very 
common to have the clonic spasms more vigorous on one side than the other. 
A hemichorea, in which the movements are vigorous and entirely confined 
to one arm or leg, is probably due to some organic cerebral disease. 

The temperature is usually normal throughout, sometimes subnormal ; 
if there is any fever, peri-endocarditis or rheumatism should be suspected. 
In the most severe cases the temperature may be raised a degree or two. 

There is often marked paresis of an arm or leg, far more commonly the 
former ; not only is the grasp feeble, but the arm is weak and powerless, 
though complete, or indeed well-marked, paralysis docs not occur. This 
paresis of an arm is sometimes the most prominent feature in the case, but 
in all cases more or less of clonic spasm maybe detected in the fingers or in 
the facial muscles. These cases have been spoken of as ' paralytic chorea.' 

The electric irritability of the muscles in cases of hemichorea has been 
studied by several observers, most recently by Gowers, cases of hemichorea 



488 Diseases of the Nervous System 

being selected on account of the possibility of comparing the muscles of one 
side with the other. In some cases no difference can be detected, but in others 
there has been noted an increase of irritability on the affected side, the 
muscles contracting with a weaker faradic and also voltaic current than those 
on the unaffected side. 

The speech is affected, in some cases from the muscles of the tongue,. 
jaw and larynx not being under efficient control. In other cases the mental 
weakness frequently present may be the cause. Headaches are often com- 
plained of; sometimes, especially in cases of 'hysterical chorea,' there is 
hyperesthesia or anaesthesia. 

Optic neuritis has been observed by Gowers, slight in degree in some 
cases ; in one case there was a sufficient degree to make it comparable to 
the neuritis seen in a case of cerebral tumour. In the vast majority of cases 
there are no ophthalmoscopic changes. 

The mental state is often peculiar. There is a vacant, listless expression 
on the face, in many cases a dullness of comprehension. The child may 
cry on the slightest provocation. There may be actual dementia, or, on the 
other hand, maniacal excitement. 

In the worst cases the movements are severe : the child constantly 
wriggles about, and the arms and legs move sufficiently violently to throw the 
patient out of bed. The constant movements of the limbs chafe the skin on 
the extensor surfaces, so that unhealthy-looking sores may result. We have 
seen such in a fatal case become actually gangrenous before death. The 
patient is sleepless, and becomes anaemic and completely exhausted. Death,, 
however, may not result from actual exhaustion, it may occur in consequence 
of pyaemia or pericarditis. Among over 634 cases there were five deaths, but 
one of these died, not from chorea, but from an intercurrent tubercular 
meningitis. All five cases were in girls ; indeed, fatal cases in boys are very 
rare. Dr. Fagge relates the case of a boy who died in nine days, and another 
boy of 12 years who died from obstructed breathing due to glossitis, the 
tongue having been severely bitten. 

The following is the history of a fatal case of chorea : 

Chorea, Endocarditis, Death. — Maggie May B. , aged 10 years. Four members of 
the same family have recently suffered from sore threats and fever due to drain smells at 
the back of the house. No history of rheumatism or previous attack of chorea. Patient 
has been attended at home by Dr. V. Brown. She has had severe chorea at home for 
two weeks. Admitted February 27, 1891. The choreic movements are moderately severe ; 
she cannot feed herself ; the heart's action is irregular, but there is no bruit ; there is 
incontinence of urine ; sordes on her lips and teeth ; temperature, q8 -ico ; sleeps badly. 
March 2. — Has been taking bromide and chloral, is quieter, and the movements are 
less ; temperature, 96°-c;8 . March 9. — Still improving, no bruit heard, sleeps better. 
March 11. — The temperature has gone up to 104° F. this afternoon ; the movements are 
now very violent ; chloroform has been given to quiet the excessive movements. Bruit 
heard for the first time at the apex. Nepenthe in 10 minim doses seems to excite ; chloral 
appears to answer better. March 16. — Has been taking bromide, chloral, and hyoscya- 
raus ; is quieter, but takes food with difficulty ; temperature, 97°-ioi°. Extensor surfaces 
of the arms are very rough and sore from friction ; there is swelling of the right parotid. 
March 19. — Much worse to-day. Respiration, Cheyne-Stokes. Died in the evening. 

Post-mortem. — Skin covering elbows and wrists roughened and abraded, ulcer on ball 
of thumb, ulcer over styloid process of radius and lower end of ulna ; both ears are 
abraded ; hair at back of head worn off ; knuckles abraded. Much swelling of right 



Chorea 

parotid. Lungs. — Old adhesions round left ; right upper lobe dark red, solid behind, 
and sinks in water ; anterior edge emphysematous ; lower lobe semisolid. There are 
patches of consolidation in the left lung ; the back of the upper lobe is engorged. Heart 
\b\oz. ) is firmly contracted, especially left ventricle. Mitral valves show recent endo- 
carditis, the edges being beaded (see fig. 55, which was drawn from this case) ; other 
valves healthy. No dilatation or hypertrophy. Intestines congested, Peyer's patches 
swollen, slightly abraded in places. Liver (44 oz.) enlarged and congested. Spleen 
[\h oz.) large and soft. Kidneys congested. Brain. — Veins on surface full. Arachnoid 
membrane opaque and cloudy, excess of subarachnoid fluid. There is a patch of what 
appears to be lymph on the convex surface. In the Sylvian fissure the arachnoid is 
especially opaque. The brain substance is firm, the capillaries are congested. 

Chorea is a chronic disease lasting for many weeks, often many months,. 
but it is usually not equally severe throughout this period. Ten weeks is 
often stated to be the average ; it certainly is often much longer. Relapses 
are exceedingly common ; it is not uncommon for children to have three to 
five attacks, but the tendency passes off after puberty. 

Complications. — In the majority of cases of chorea the heart is in some 
way or other affected. In some cases chorea apparently supervenes in 
children who are suffering from chronic heart disease ; in a few cases it 
appears to be brought on by an attack of pericarditis, but in the majority of 
cases the heart complication comes on during the course of an attack of 
chorea. Out of 252 cases of chorea, nothing abnormal was noted in the 
heart's action in 79 ; in 54 there was irregularity or reduplication of the 
sounds ; in 1 19, bruits, mostly heard at the apex more loudly than at the base r 
were detected. Some of these bruits were, no doubt, anaemic, inasmuch as- 
they were present only at the base ; it is seldom, however, possible to say 
dogmatically that a bruit heard during the course of chorea is simply haemic, 
and it is necessary to have the patient under observation for a long period 
during convalescence before we are in a position to say if a so-called haemic 
bruit is due to organic disease or not. It is well also to remember that 
endocarditis may occur and yet no bruit be produced ; thus we have 
sometimes failed to detect bruits in cases of chorea, but some months after- 
wards have noted undoubted organic murmurs. Both mitral and aortic 
valves may be affected, though the former are far more commonly affected 
than the latter ; while many of those in whom bruits are heard during chorea 
have suffered from rheumatism, this is by no means the case with all. 

Acute or sub-acute rheumatism was associated with chorea in 46 out 
of 252 cases, while 20 more, according to their friends' account, suffered from 
' rheumatic pains.' Statistics with regard to the association of chorea and 
rheumatism vary considerably, but this is hardly surprising, inasmuch as we 
are largely dependent upon the histories given by friends, and their ideas 
concerning rheumatism are apt to be vague ; moreover, the symptoms oi 
rheumatism are often less well-marked in children than in adults, and 
rheumatic attacks may be easily overlooked, or at least may not be recog- 
nised as rheumatic. The association of rheumatism and chorea is undoubted, 
and cannot be a mere coincidence ; not only do we see children suffering 
from chorea attacked with rheumatism, and vice versd, but not infrequently 
we see a sister suffering from chorea and a brother from rheumatism, or 
attacks of chorea and rheumatism alternating in the same individual. 
Rheumatic nodules are present in a few cases. 



490 Diseases of the Nervous System 

The following case illustrates the association of chorea with rheumatism : 

A Case of Clwrea attended by Paresis and Loss of Speech for eighty-one days, and com- 
plicated with Peri-Endocarditis and many Fibrous Nodules. Death after 8£- months 
illness. — Edith M. N., aged 9 years, the daughter of a surgeon, was fairly strong and 
enjoyed good health till early in June 1889, when it was noticed she had developed 
decided choreic movements ; for three or four weeks previous to this some premonitory 
symptoms, such as excessive fidgetiness, had made their appearance. In the previous 
September, eight months before the beginning of the illness, she received a severe fright 
when away from home, and since then had been subject to peculiar nervous attacks. 
There is a strong rheumatic history in both parents. 

During the early weeks of June the choreic movements steadily increased, and were 
most marked in the face and right side of the body. Her speech was affected, and on 
June 19 she lost the power of speech, a condition which lasted for eighty-one days. 
About this date she lost control over her limbs ; any attempt at voluntary movement 
rendered the involuntary movements stronger and more erratic. She was unable to 
change her position in bed, and, indeed, on one occasion was nearly suffocated by slipping 
■down under the bedclothes and being unable to extricate herself. On the same date 
several joints became tender, being most marked in the right elbow and wrist. 

During the next few days the movements became more violent, all the limbs being 
tossed about, the head jerked and banged from side to side, and the features constantly 
■contorted. She was fed with difficulty, on account of the movements of the muscles of 
mastication and a difficulty of swallowing. Early in July a mitral regurgitant bruit was 
detected, rheumatic pains were constant, and fibrous nodules made their appearance. 
The ' rheumatic ' pains varied, sometimes the joints were tender, at other times there were 
shooting pains down the legs ; the first nodule noticed was over one of the spinous pro- 
cesses of the cervical vertebrae. These nodules were followed by many others, which 
made their appearance during the succeeding two or three months. At one time there 
were at least 200 present, being situated on the scalp, borders of the scapulae, along the 
ribs, tendons of the hands and feet. There was one present over each spinous process, 
presenting an appearance resembling Dr. Cheadle's illustration in the Lancet, May 4, 1889. 
They varied in size from a pea to a large filbert, and in some places, especially on the 
back of the head, they presented an almost bony hardness. 

The choreic movements at this time were exceedingly severe, continuing both night 
and day, the patient obtaining very little rest. The tongue and mucous membrane of the 
cheeks and lips were bitten, and troublesome ulcers resulted. The lower jaw was retracted, 
apparently from spasm of the muscles, so that the lower incisors closed inside the upper 
incisors. There were frequent involuntary movements of the bowels and bladder. 

On July 12 a friction sound was heard over the cardiac region, followed by a large 
•effusion into the pericardium, with a weak and rapid pulse. By the end of July the fluid 
in the pericardium had diminished in quantity and the dyspnoea was less urgent than it had 
been. The choreic movements were less violent, but a paresis of the extensors of the 
fingers and an over-action of the flexors was noted, so that a ball of cotton wool had to 
be kept in the palms of the hands to protect the skin from being injured by the nails. 
.Another noteworthy point was the extreme retraction of the jaw. The emaciation and 
exhaustion had now become extreme. 

In August another attack of pericarditis occurred, with effusion, and as the fluid 
became absorbed the systolic murmur noted a month before became louder ; there was also 
a thrill and a distinct presystolic bruit. 

The condition remained much the same during August and the early part of September ; 
at this time she was kindly seen by Dr. W. B. Cheadle, of London. On the evening of 
September 8 the power of speech suddenly returned, and from this time she was able to 
-converse with her friends. Later she suffered from several fresh attacks of rheumatic 
pains and violent attacks of pain over the praecordial region. 

During the latter part of September and during the next two months gradual improve- 
ment took place ; the movements ceased, the paresis of the limbs disappeared, and she 
was able to walk with help ; but the heart evidently became more and more enlarged, and 
the systolic bruit more marked. 



Chorea 49 1 

In January signs of cardiac failure set in ; there was enlargement of the liver, great 
anaemia, dyspepsia, and dyspnoea on exertion. There were also frequent attacks of 
severe cardiac neuralgia, the pain being referred to the precordial region, and there was a 
sense of constriction round the waist. Early in February oedema of the feet came on, 
while the attacks of cardiac pain were most distressing, and continued till her death on 
February 19, the illness having lasted nearly nine months in all. 

This case illustrates in a remarkable manner the close association between 
chorea and the rheumatic state, and the damage which the heart may suffer 
in the young without the patient suffering from a typical attack of articular 
inflammation. Apart from the severe chorea from which the patient suffered, 
there was a continuance of the 'rheumatic state ' for several months, during 
which time there were joint tenderness, shooting pains, acid perspirations, 
•continuous crops of ' fibrous nodules,' patches of erythema, and repeated 
attacks of peri-endocarditis. It is evident that the latter was chiefly in- 
strumental in bringing about the fatal termination, for it was clear there 
was not only a damaged mitral valve, but the frequent attacks of pericarditis 
must have bound the heart tightly round with fibroid adhesions. One of the 
unusual features in the case was the distressing cardiac neuralgia, the pain 
over the heart appearing to be intense, and the sense of constriction round 
the chest being very marked and difficult to relieve. There was doubtless a 
labouring ill-nourished heart struggling with its load. 

Of what prognostic importance were the large crops of fibrous nodules ? 
We may certainly say they pointed to the intensity of the 'rheumatic' state, 
and the consequent probability of recurrent attacks of peri-endocarditis. 
It is worthy of note that these nodules were mostly situated over prominent 
parts, and where, in the choreic state of the patient, friction would be most 
intense. Thus they were present on the back of the head, o\ er the spinous 
processes, and along the edges of the scapula. In the rheumatic state, as 
Dr. Cheadle insists, there is a special liability to irritative lesions of the 
nbrous tissues ; this is seen in the nodules — which are caused by a prolifera- 
tion, and cell-infiltration of tlie fibrous tissue — and in the endocardial, peri- 
cardial, and pleural inflammations. If, as he believes, there is a close re- 
lationship between the fibrous nodules and peri-endocarditis, the significance 
of the occurrence of nodules cannot be overrated. 

Perhaps the most interesting features in the case were those connected 
with the nervous system. For nearly three months the patient did not 
speak and the only sounds made consisted of a sort of ' grunt." She was 
perfectly sensible and rational, and would try to nod or shake her head, but 
any attempt at speaking, especially when the chorea was at its worst, made 
the involuntary movements of the face and neck more violent. The cause 
of the loss of speech was doubtless due to a loss of control over the muscles 
•of the tongue and lips. This was also manifested in the difficulty of mas- 
ticating food. The power of speech entirely returned, and was retained up 
to the time of her death. 

Another peculiar system was the retraction o\ the jaw, which was well 
marked, apparently being caused by over-action o[' the retractor muscles. 
In the later stages of the choreic attack, the weakness o\ the arms and the 
over-action of the flexors of the fingers were well seen. The hands were 
tightly clenched, and any attempt to force them open gave pain and brought 



49 2 Diseases of the Nervous System 

on a more convulsive action of the flexors of the fingers. There was also 
some rigidity of the legs, with pointing of the toes. At this period there was 
much wasting of the muscles, with a certain amount of tenderness on pressure 
over them. 

A paresis of one arm not infrequently takes place in chorea; such cases 
have been described as paralytic chorea. It consists in weakness rather 
than paralysis, and not infrequently precedes the other symptoms of chorea, 
A peripheral neuritis in rare cases appears to follow chorea, as it does 
also rheumatic attacks, the principal phenomena being muscular wasting 
and paresis, indefinite pains such as ' pins and needles,' and in some instances 
anaesthesia. 

In some cases there is sufficient excitement of the brain to merit the 
name of maniacal chorea or chorea insaniens. This condition is most 
common at or about puberty. There may be violent delirium and excite- 
ment, so that the patient has to be controlled by her attendants, the attacks 
resembling acute mania. Often these attacks are closely allied to or resemble 
hysteria. The following case appears to have been one of this kind : 

Maniacal Chorea ; Hysteria. — The patient was a girl of fourteen years of age ; both 
her sister and herself had chorea a year and a half before the present attack, which lasted 
for some time, and for which she was treated in the Derby Infirmary. She was readmitted 
with choreic movements of moderate intensity, but they were readily controlled by the will, 
and she was perfectly rational. She got worse, the movements being more violent ; there 
was difficulty of speech, she became extremely emotional and at times maniacal. When 
she was moved — as, for instance, when her bed was made — she would struggle and run 
her nails into the attendants. Two months after admission the knees became semiflexed 
and rigid, and there was incontinence of urine and faeces. She was so troublesome that 
she was sent home after about three months in hospital. 1 Some time after she was 
admitted to the Children's Hospital. At this time she had sordes on her lips and teeth, 
she was much emaciated ; both knees were semiflexed and rigid, the hips were semi- 
flexed and rigid ; the patellar reflex could not be obtained on account of the excessive 
rigidity. There were slight choreic movements of the arms and face ; she passed her 
urine and faeces into bed. She was extremely emotional, and there was some hyper- 
aesthesia, especially about the joints and muscles. She gradually began to improve in a 
week or two, having more control over the sphincters, and the legs became less rigid and 
she gained flesh. A fortnight after admission the bedsores had healed, and she was less 
emotional. In a month she could walk with help, and in three months she was discharged 
quite well. 

In this case there seems to have been aggravated hysteria associated 
with chorea, though at one time the girl looked very much as if she was 
suffering from organic brain disease. The emaciation, bedsores, and rigid 
legs seemed to point to an organic lesion : this was, however, negatived by 
her complete recovery. 

In some rare cases instead of paresis there is muscular spasm, which may 
persist for some time after the choreic movements have disappeared. The 
following case illustrates this : 

Chorea; Muscular Spasm. — A boy, aged ioi years, was admitted to the Children's 
Hospital suffering from chorea, which was attributed to a fright, he having seen a ' ghost 
at a show.' Three sisters had also suffered from chorea, one having died during an attack. 
His attack was a moderate one ; no bruit was heard, there was some paresis of his right 



1 These notes were kindly furnished by Dr. \Y. Benthall, of Derby. 



Chorea 493 

leg. He was discharged in a month's time quite well. He was readmitted two months 
later, the choreic movements being pretty much confined to the right arm, which was 
markedly weak ; the right knee joint and ankle were rigid, the muscles being in a state of 
spasm ; there was no pain or tenderness. There was a systolic bruit at the apex. He was 
discharged in six weeks ; the choreic movements had disappeared, but the spasm in the 
right leg persisted. He had another attack of chorea eighteen months afterwards ; before 
this occurred, the muscular spasm had entirely disappeared. 

Hemicliorea. — In many cases, as already pointed out, the movements 
are confined to one side of the body, or at all events they are more marked 
on one side than the other. Hemichorea is in some instances post-hemi- 
plegic, following some months or more after the hemiplegia, when contrac- 
tures are present, as in the case of cerebral tumours situated near and in- 
volving the internal capsule or pyramidal tracts ; choreiform movements 
may take place on the opposite side. In hemichorea symptomatic of brain 
disease the movements are vigorous and grotesque, the fingers, hands, feet, 
and extremities being twisted and jerked about. In one of our cases, in a 
boy of five years of age, who had a cheesy tumour in the right optic thalamus, 
at first sight the child appeared to be affected with the ordinary form of 
chorea. His left arm was in constant movement, the result of short, irregular, 
jerky contractions of the muscles of the forearm and arm, following one 
another with great rapidity, and closely resembling those seen in a severe 
case of chorea. When the boy was at rest the arm was quiet, only a sort of 
fumbling movement of his hand being noticed, but on asking him to sit up 
or give his hand, vigorous, almost violent, movements began again. Some of 
the movements were produced by all the muscles of the arm, yet some of the 
muscles acted more continuously and powerfully than others, so that the 
arm tended to be held to the side and more or less behind, while the fore- 
arm was pronated and the wrist flexed, the fingers being in continual move- 
ment. This condition of hemichorea differs from ' athetosis ' or 'mobile' 
spasm already described (p. 477). 

Morbid Anatomy. — Various minute changes have been described in the 
brain in fatal cases of chorea, but it is quite certain that no constant and 
invariable lesion has been discovered. Embolism and thrombosis of the 
minute vessels of the cortex and basal ganglia have been described ; minute 
spots of softening, changes in the nerve cells, and enlarged perivascular 
spaces have also been found. We cannot say that any of these observations 
throw any light on the morbid anatomy of the disease, especially when we 
remember that on various occasions competent observers have found 
nothing of importance in their examination of the brain and spinal cord in 
fatal cases. Many of the changes described ave no doubt secondary, the 
result of hyperemia of the nervous centres. 

The frequent association of chorea with rheumatism and endocarditis 
suggested to Kirkes the idea that chorea was the result o( minute embolism 
of the brain by fragments of fibrin washed oil the mitral valves. This 
hypothesis, however, is quite inadequate to explain the phenomena presented 
by the disease ; thus chorea has followed within a few hours o( a sudden 
fright, and moreover fatal caseshave been recorded (though rarely) in which 
no endocarditis has been found. Embolism will not explain those cases of 
'reflex chorea' in which the exciting cause is an acute otitis, or when chorea 



494 Diseases of t/ie Nervous System 

follows some injury or accompanies pregnancy ; we find that pericarditis, and 
perhaps endocarditis, act as exciting causes operating through the nervous 
system, Justin the same way as some gastric-intestinal irritation may be the 
exciting cause of convulsions in infants. 

In considering the pathology of chorea we must take into account the 
associations of chorea, though it cannot be said they help us much in coming 
to a conclusion. Chorea is associated, on the one hand, with rheumatism 
and endocarditis, and on the other with hysteria and mania ; the former 
association would suggest a blood-change, the latter simply a functional 
disturbance of the nervous system. Pathologists in formulating their 
theories have leaned either to the one or to the other. Sometimes chorea 
has been explained as secondary to endocarditis, as a result of capillary 
embolism, or as the result of a ' rheumatic ' condition of blood, in which 
some chemical poison has been present in the blood which has a specific 
action on the nervous system. At other times chorea has been looked upon 
as an emotional disease, and, like hysteria, a purely functional disease, or, as 
it has been termed, an ' insanity of the muscles ' or motor region of the brain, 
just as mania or other forms of insanity affect the seat of the mind. 

There has been also much difference of opinion with regard to the seat 
of the disease ; it has been placed in the spinal cord, basal ganglia, and 
cortex of the brain. The fact that the face is usually affected, and that more- 
over the choreic movements are frequently one-sided, would almost certainly 
point to the seat of the disease being within the cranium. The tendency of 
recent researches in physiology has been to deprive the corpus striatum of its 
alleged function as an originator or co-ordinator of motor influences, and to 
assert that it has little or nothing to do with the discharges of motor force. 
On the other hand, there is strong reason to believe that the choreic move- 
ments are the result of irregular discharges from the motor region of the 
cortex ; for the time being the will or the inhibitory influence of the frontal 
regions is in abeyance, and irregular purposeless discharges are given out 
from the cells in the motor region of the cortex. There is much reason to 
believe that the functions of the cortex are impaired in chorea, as shown not 
only by the spasmodic movements, but also by the paresis which sometimes 
occurs, and the mental dullness and emotional disturbance so often present. 
It can easily be understood that if there is impaired nutrition of the nerve 
centres, a sudden fright, or an irritation at some distant part, may start the 
irregular discharges from the cortex, which it may soon be beyond the power 
of the will to control. 

With regard to the cardiac complications found in fatal cases we cannot 
do better than quote Dr. Sturges, who sums up as follows : 'Vegetations, new 
or old, on the auricular surface of the mitral valves, with or without similar 
deposits on the aortic valves, and sometimes with pericarditis, are met with 
in the great majority of cases dying of, or with, or shortly after, chorea. 
This condition, however, does not, as a rule, contribute directly to the fatal 
issue ; it is found equally among those that die with and those that die of 
chorea, and in some of the most marked and typical cases of fatal chorea 
the valves of the heart have been found absolutely healthy.' 

Diagnosis. — This is not usually difficult, though it must always be borne 
in mind that the choreic movements present may be symptomatic of some 



Chorea 495 

serious brain lesion, or of some distinct disturbing - influence, such as 
pericarditis. We have seen on one or two occasions, in girls about puberty, 
choreic movements followed by emotional disturbance and paresis of limbs, 
attributed not unnaturally to hysteria, where the onset of optic neuritis and 
amblyopia has made it clear that the case was really one of cerebral 
tumour. We have seen also the onset of chorea in a girl of four years followed 
in a week by pericarditis and death in a few days. 

Any brain lesion which presses upon the pyramidal tract may give rise tO' 
movements similar to chorea ; we have several times seen this in cheesy 
tumours of the optic thalamus which compressed the internal capsule ; in 
such cases a ' hemichorea' is produced (see p. 493). It must be borne in 
mind that in true chorea, if at all intense, the movements are general, though 
perhaps worse on one side than on the other, but they are never confined to 
one side, as in the case of cerebral tumour. 

In some of the special varieties of the disease the diagnosis may be 
difficult ; thus in the case related (p. 492), where there was contraction of the 
limbs and bedsores, one might readily assume that chronic meningitis or 
other cerebral lesion was present. In a case under our care, where tuber- 
cular meningitis supervened in the course of chorea, the diagnosis was un- 
certain for a few days. The presence of optic neuritis would strongly 
point to organic disease, though, as already stated, Gowers has observed 
optic neuritis in a case of chorea. In cases of paralytic chorea the chief 
symptom may be simply paresis of one arm ; but usually a slight ex- 
amination will detect short clonic spasms, either in the affected arm or 
elsewhere. 

Prognosis. — Recovery follows in the vast majority of instances. The 
principal danger is from some heart complication, as pericarditis, and from 
exhaustion in consequence of the violence of the movements, want of sleep, 
and nourishment. The more severe the case, the longer will be its duration. 
Maniacal and hysterical choreic cases are usually very chronic. 

Treatment.— The, most important element in the treatment of chorea is 
rest. It is necessary to secure for a patient suffering from chorea complete 
rest for the body, and complete absence of excitement of all kinds. In all 
but the mild cases it is well to begin the treatment by keeping the patient 
for a few days or a week in bed completely at rest. We must bear in mind 
that voluntary movements of all kinds (in severe cases at least) make the 
involuntary movements more marked and more completely beyond the 
control of the will. On the other hand, the movements cease during sleep. 
and the more quiet a patient can be kept, the better chance there is ol~ a 
better nutrition of the body and the nervous centres. Any excitement or 
mental effort is certain also to make matters worse, so that all forms ot 
mental work must be avoided, while the surroundings of the patient must be 
made as agreeable as possible. When the movements are severe, so that 
the patient cannot sleep, some narcotic must be prescribed, and oi remedies 
of this class chloral is probably the best, but it must be given in full doses 
to be of use. Ten or fifteen grains may be given, and repeated in four hours 
if the restlessness continues, Bromide of potassium may be combined with 
the chloral, though most agree that chloral is more useful than the bromide. 
Morphia seems at tunes to add to thoexciicment present, though in some c 



496 Diseases of zhe Nervous System 

it acts better than chloral. In the case recorded on p. 490 (girl aged nine 
years), chloral and bromide entirely failed. Nepenthe in 10-minim doses 
gave sleep ; later in the disease as much as 30 minims, and on one occasion 
70 minims, were given in one night. This was, of course, only after a toler- 
ance of the drug had been established. Inhalations of chloroform are often 
useful to get the patient off to sleep. Great care must be taken to prevent 
the patient from injuring herself by tumbling out of bed, and it may be 
necessary to protect the limbs by wrapping them up in cotton wool, or to 
surround them with some soft material ; or padded boards may be placed on 
each side of the bed, or a mattress may be placed on the floor. The patient 
should be given a fair amount of liquid nourishment, and also stimulants. 
Frequent spongings are of great value in getting the skin to act and calming 
the patient. 

Even in the less severe cases of chorea it is well to confine the patient to 
bed for a week or two in the early stages ; the movements are always less 
when the child is at rest in bed, and these means are almost certain to shorten 
the duration of the attack. When improvement occurs the patient may be 
allowed to get up for a few hours a day and to be taken out into the fresh 
air, but too much exercise should be prevented. 

The drug which is most used at the present time is arsenic ; sulphate or 
oxide of zinc, cannabis indica, iron, Calabar bean, and conium have also been 
used. We confess to some scepticism with regard to the value of medicines 
in chorea, and feel sure they occupy only a subsidiary place in treatment. 
Arsenic is certainly of use in the dyspeptic conditions which so often 
accompany chorea, but it requires to be given in increasing doses as the 
stomach becomes more and more accustomed to it. Two- or three-minim 
doses may be given three times a day at first, and increased at the rate of 
an extra minim every week till six or seven minims are given. It is better 
not to continue the administration for too long together, as a temporary 
darkening of the skin is apt to take place. The administration may be 
omitted for a week or two, and then recommenced. In the latter stages iron 
may be useful, given in combination with arsenic. 

Great care should be taken to regulate the bowels ; constipation is the 
rule, and this may be overcome by small pilules of extract of aloes or some 
elixir of cascara sagrada. 

In chronic cases a change of scene, such as residence at the seaside, is 
often suggested by the friends, but in our experience this change often 
makes the movements worse and prolongs the attack, in consequence of 
the excitement attending the change and the patient attempting to do more 
than her strength permits. A change to the seaside should be deferred till 
the movements have nearly ceased and can be controlled entirely by the will. 
The same may be said of gymnastic exercises and rhythmical movements ; 
they are of the greatest use when the movements tend to become habitual, 
while the health of the patient is good : they are certainly not desirable in the 
earlier stages. Massage has been employed with good result by Goodhart 
and Phillips, and in some of our own and our colleagues : cases the result 
has been satisfactory. 

All through the course of chorea moral treatment is of the greatest im- 
portance. Chorea in many cases is closely allied to hysteria, and a firm but 



Epilepsy 497 

kindly demeanour towards the patient is called for ; and she should be 
■encouraged to control the movements as much as possible by an effort of 
will. In all severe cases a nurse should be provided, as the patient's mother 
is often the last person who should have charge of her. 

In all stages of the attack a nourishing, easily digested diet is necessary ; 
in severe cases it is necessary to feed the patient ; in such patients fluid food 
only can be administered. 

Epilepsy 

Convulsive seizures of various degrees of severity are common during 
childhood and youth, and when they are idiopathic — that is, without assign- 
able cause, no cerebral or other lesion being discoverable — the term 
'epileptic' is applied to them. It is difficult to say in what proportion of 
■cases children who suffer from convulsions during infancy become confirmed 
epileptics ; certainly the majority of those who suffer from infantile con- 
vulsions lose this tendency to convulsive seizures as they grow older. In 
only about \i\ per cent, of cases of chronic epilepsy is there a history of 
the fits commencing during the first three years of life, and in a smaller 
percentage (5^) during the first year. (Gowers.) According to statistics 
collected by Gowers, in one-fourth of the total number the attacks begin 
before the age of ten years, and nearly one-half between the ages of ten and 
twenty years. These statistics show that there is always the possibility that 
children or infants who suffer from reflex convulsions may become epileptics ; 
yet there is a strong probability, if the child does not suffer from any cerebral 
defect, or has no hereditary tendency in the direction of epilepsy, that he will 
not grow up an epileptic. Hereditary influences certainly predispose ; a 
family history of epilepsy or insanity is obtained in about one-third of the 
cases of epilepsy, in others it may be found that they come of neurotic 
families in which members have suffered from chorea or hysteria. 

Of the exciting causes there is little to be said, The first fit may be 
described by the friends as being due to a ' sunstroke,' or a ' blow on the " 
head,' or a 'fright ;' but it is unsafe to place much reliance on such state- 
ments, as they may be merely coincidences, and certainly are not sufficient 
in themselves to produce epilepsy. In the large majority of cases, it must be 
confessed, no immediate cause can be discovered. Epilepsy sometimes 
commences after scarlet fever and other zymotic diseases, but beyond the 
fact that these fevers leave a certain amount of weakness behind, and so may 
predispose, there is nothing to suggest that they act as effectual causes. The 
approach of puberty is a time when the nervous system is in an excitable 
state, especially in girls, and epileptic fits are very apt to commence at this 
period, notably in cases where menstruation does not commence at the 
usual period, but is delayed by any cause. Constipated bowels and a slug- 
gish condition of liver certainly act as predisposing causes. 

Symptoms. — Two forms of attack are usually described : the minor form. 
ox petit mat, and the major form, or grand mat ; but these two forms insen- 
sibly pass into one another, and there is no marked line of demarcation 
between them. 

The precursory symptoms differ very much : frequently the first tits and 
the succeeding (its come in the midst o( perfect health, and neither the 

K K 



49 8 Diseases of the Nervous System 

patient nor his friends are aware that a fit is imminent. On the other hand r 
the child may be unusually irritable, easily put out, and nothing pleases it j 
it may be feverish, dull, and stupid. In some cases the fit is preceded by 
some warning or aura, by which the patient becomes aware, by past 
experience, that an attack is at hand. These auras are more common in 
adults than in children, or at any rate adults are better able to describe their 
feelings and have a larger experience of fits to fall back upon. The auras are 
very diverse in character : they may be sensations referred to an arm or leg,, 
or to the throat ; there may be headache, vertigo, or faintness. 

Petit mat. — These minor attacks are very slight in character and are 
often not admitted to be epileptic by the friends, who usually connect ' fits ' 
with the more severe and decided form of seizure. They are often spoken 
of as ' faints ' or ' attacks.' There may be no real convulsion or tonic spasm ; 
the child may stumble when walking from a momentary impairment of 
consciousness, a peculiar look crosses its face, and for a moment it is dazed 
and forgets what has happened. Sometimes the face becomes pallid for 
a moment, and there is a slight convulsive spasm of the facial or other 
muscles. The urine is rarely passed in these seizures, nor is there any cry. 
Sometimes the attack is succeeded by drowsiness or stupor. In older 
children the behaviour may be very peculiar : after one of these minor 
seizures a mild mania may seize the patient, he becomes mischievous or 
strikes other children without provocation, or behaves in an hysterical 
manner. 

Grand mat. — The seizure may begin with a sharp cry or scream, as of 
sudden fright ; in many cases this cry is absent, the patient falling precipi- 
tately on to the ground in an unconscious state. The face is pallid and 
tonic spasms of the muscles begin. Sometimes these are one-sided in dis- 
tribution : the muscles of one side of the face, neck, arm, and leg of the same 
side are thrown into contraction, the head is usually rotated to the affected 
side. In other cases the spasms are general. The legs are usually extended 
and stiff, the elbows partially bent, the wrists flexed, and the fingers in a 
position of interosseous spasm. (Gowers.) The respiratory muscles join 
in the general tonic spasm, and, as the inspiratory muscles are more powerful 
than the expiratory, the breath is drawn in and held, so that the face becomes 
congested and the lips blue. There is usually spasmodic contraction of the 
muscles of the jaw, so that the tongue is bitten and held between the teeth ;. 
frothy, perhaps blood-stained, saliva runs from the patient's mouth. Death 
may take place from asphyxia during this stage. Usually, however, after 
the stage of tonic spasm has lasted from a few to thirty seconds, the con- 
tinued spasm of the muscles relaxes, and clonic or intermittent short con- 
tractions succeed. The muscles of the face twitch ; so that the patient 
appears as if he were making grimaces ; the limbs * work,' alternately flexing 
and extending— sometimes so violently that the head and legs are banged 
about and become bruised and injured. In other cases the clonic spasm is 
not so vigorous, there being only short, sharp, muscular contractions. The 
urine and sometimes the faeces are passed. The period of the clonic spasm 
is variable : it may last many minutes, or even hours ; the patient gradually 
recovers consciousness, and has no recollection of what has passed. He 
probably is dazed and sleepy, goes off to sleep, and wakes up tired and sore.. 



Epilepsy 499 

The fits vary much in intensity : often the stage of tonic spasm is short and 
not well marked, and the whole duration of the fit is not more than half a 
minute. In some cases, especially after severe attacks, a temporary para- 
lysis, mostly hemiplegic, is left. We are inclined to attribute this to a 
meningeal haemorrhage which has taken place during the respiratory spasm. 

Hysteroid Fits. — Some minor attacks closely resemble hysteria in that 
the spasmodic movements are of a purposeful character, as if directed by 
the will, and, moreover, the child appears to be conscious or semi-conscious 
during the fit. This form of seizure is common both in boys and girls. 
The phenomena which take place are exceedingly various ; the child may 
commence by barking like a dog, or mewing like a cat, or may attempt to 
bite its attendants ; the head may be banged about and the legs and arms 
thrown wildly about, as if the child were directing the movements. The 
patient may stiffen out and arch his back as in opisthotonos. Sometimes 
the actions are still more co-ordinated. Thus in a girl of seven years, in 
hospital, when an attack came on she would jump up in bed, turn round 
once or twice, sit down again and arrange the bedclothes, smoothing them 
carefully down, and yet be unconscious during the fit, and have no remem- 
brance of it afterwards. A sharp word or the prick of a pin will often 
arrest these fits. That some of these cases are closely related to epilepsy is 
shown by the fact that they may alternate with true epileptic fits, or they may- 
supervene at puberty in children who have suffered from chronic epilepsy. 

Post-hemiplegic Epilepsy. — Children who suffer from hemiplegia which 
dates from birth or within a year or two of birth are very apt to suffer from 
epileptiform attacks. Convulsions are very apt to attend the onset of the 
hemiplegia : the child may continue to have fits, and be subject to them for 
the rest of its life. In other cases a period of months or years may elapse 
between the onset of the hemiplegia and the commencement of the epileptic 
fits. It is often about puberty that they recur. As a rule, the convulsions 
affect the paralysed side only, but in severe cases the convulsions may be 
general. An aura or warning of the approaching fit is more common in 
post-hemiplegic epilepsy than in idiopathic epilepsy. In these cases it is 
common for mental backwardness to exist (see case, p. 474). 

Course. — As already stated, the epileptic fits may date from infancy the 
child having suffered in the early months or years of its life from convul- 
sions, and these have been succeeded by chronic epilepsy. More often the 
child has been free from convulsive seizures during infancy and only child- 
hood, and it is only during the second dentition or as puberty is approached 
that it has begun to suffer from fits. The health prior to the commence- 
ment of the fits may have been excellent, there maybe no history of epilepsy 
in the family, and it may be quite impossible to explain the onset of epileptic 
fits. At first the friends are loth to believe the tits to be epileptic, and attri- 
bute them to rapid growth, dentition, weakness, or some injury. In other 
cases the health may have been indifferent or the temperament peculiar, 
the child having been of a strange disposition, nervous, easily frightened 
morose, or backward in mental development, or may have shown signs ol 
idiocy, and then, as puberty approaches, commences with epiletic tits. The 
health of the child after the commencement o\ the tits varies accordin 
their frequency and severity, In the milder forms the children may enjoy 



500 Diseases of the Nervous System 

the best of health, may be merry, romping children, able to take their part 
in rough school games, and be of average or more than ordinary quickness 
and intelligence. In other cases, especially when the fits occur frequently, 
the health suffers, the patient becomes sallow and anaemic, his digestion 
and appetite are poor, and the liver and bowels sluggish. The memory is 
apt to fail more or less, and in the worst cases a condition allied to dementia 
may supervene. The intervals between the fits differ considerably, not only 
in different patients, but in the same individual ; sometimes many months or 
even years will pass without a fit, at other times the fits follow one another 
at intervals of a few minutes, so that the patient is no sooner out of one fit 
than he is into another. To this latter condition the term 'status epilepticus : 
has been applied. In the petit mat the fits usually occur oftener than in 
the more severe attacks. Fits may occur at any time in the twenty-four 
hours, at night or by day. but there seems to be a special tendency for them 
to recur in the early morning when the patient is getting up. 

Prog?wsis — The prognosis is bad in those who have suffered from fits 
from infancy, and who are mentally deficient or in whom some mental 
change has taken place. The chance of the entire cessation of the fits is a 
poor one in those who have fits frequently. The less frequent the fits, the 
greater is the probability that they may cease altogether. Even in those who 
have only suffered from fits at long intervals a cautious prognosis must be 
given, as those who have so suffered are never safe, and a recurrence may 
at any time take place. The danger to life is least in the minor attacks, but 
as time goes on the major attacks may supervene. There is always the 
possibility that the fits may cease when the epoch of puberty is passed, and 
in the case of girls when menstruation is thoroughly established. It must 
always be borne in mind that epileptics may at any time meet with a sudden 
death from injuries received during a fit : they may fall into the fire, or into 
water, or they may be suffocated in bed at night. Less often death takes 
place in the fit from asphyxia, due to prolonged spasm of the glottis and 
respiratory muscles. 

Diagnosis. — In some cases of petit mal the attack may be so slight that a 
doubt may exist whether the fits are really epileptic or not : but all recurring 
' faints ' or attacks of giddiness must be looked upon with great suspicion, 
and if there is a loss of consciousness, however short, they are almost 
certainly epileptic. Difficulty may often arise in distinguishing hysterical 
attacks from true epilepsy, especially the attacks described as hysteroid. It 
may be simply a matter of opinion whether some of these attacks are best 
classed with epilepsy or hysteria ; in any given case careful inquiry must be 
made for typical epileptic fits, which sometimes occur immediately before 
the hysteroid fits. The diagnosis is usually easy between typical epileptic 
and typical hysterical fits ; it is often very uncertain in atypical ones. Loss 
of consciousness, biting the tongue, or tonic followed by clonic spasms, if 
present, are decisive in favour of epilepsy. There may often be considerable 
difficulty in distinguishing between reflex convulsions and epileptic fits. 
Under three years of age, if there are the signs of rickets, the probabilities 
are strongly in favour of their being reflex. After this age reflex con- 
vulsions may occur at the commencement of some zymotic disease, or 
possibly as the result of cutting the permanent teeth, or from worms ; but the 



Epilepsy 501 

chances are immensely in favour of epilepsy if they are on the type of those 
in idiopathic epilepsy ; in all cases where the attacks are epileptiform in 
character, in which there is loss of consciousness, spasm followed by stupor, 
even though the child is cutting one of the permanent teeth or had worms, 
we should be inclined to believe they are really epileptic. Parents naturally 
like to believe that the fits are due to dentition, to rapid growth, to a dis- 
ordered liver or stomach, especially in those cases where there are no here- 
ditary tendencies present, but we cannot accept these as anything more than 
exciting causes, and in all such cases there is only too much reason to fear 
that there may be a recurrence of the attacks. Convulsions may occur as the 
result of brain disease, recent as well as old. A tumour or syphilis may be 
present in this case ; there may be some marked aura, especially visual or 
auditory ; the convulsions will be mostly one-sided ; moreover, there is 
headache, giddiness, vomiting, paralysis, and optic neuritis. 

Treatme?it.—A child subject to epileptic fits should be placed under the 
most favourable conditions possible, and should be most carefully guarded 
from excitement, over-fatigue, and over-feeding. A healthy country life, with 
plenty of outdoor exercise and sufficient employment for the mind, must be 
enjoined. A moderate amount of brain work maybe allowed, but no forcing 
of any kind should be permitted. It is well to allow no work and not much 
exercise before breakfast, as at this time there appears to be an especial 
liability to fits. The diet should be simple and unstimulating ; in some cases 
coming under our notice children have done better when butchers meat 
has been excluded from their diet or only taken sparingly. How useful a 
regular life is, is seen by the improvement which nearly always takes 
place on the child's admission to hospital. It is needless to say that all 
children subject to fits should be carefully watched : a public or large 
school is certainly not the place for them, as they require more individual 
attention than is possible under such conditions. There is always the 
possibility that they may fall into the fire, or into water, or be suffocated 
in bed by a fit occurring during the night. The state of the bowels should 
be most carefully attended to, as there can be no question that constipated 
bowels predispose to the attacks. Effervescing citrate of potash, magnesia, 
or cascara, with occasional small doses of calomel, are useful. Of all medicines 
which check the tendency to fits the bromides take first place. Bromide of 
potassium or sodium may be given in doses of 10 to 40 grains a day, according 
to age and to the frequency of the fits. The saline taste is readily covered 
by well diluting with water, and adding syrup of orange peel, aromatic sp. ot 
ammonia, or liq. ext. of liquorice. (F, 29.) 

Sometimes a laxative may be combined with the bromide to counteract 
its constipating action : sulphate of magnesia, tincture or infusion oi rhu- 
barb, or 'cascara cordial' or 'elixir,' may be used, but, as a laxative can be 
given as required, it is usually unnecessary to combine one with the bromide. 
The bromide should be administered for a month at least after the tits, and 
then may be reduced in quantity ; but it will be well to continue the use of 
bromide in gradually smaller doses for six months at least after the last fit ; 
it may be combined with digitalis or tonics such as cinchona, iron, or nux 
vomica. 

five rise to a lethargic heavy condition in the 



502 Diseases of the Nervous System 

patient ; there maybe slow drawling speech, and a slow circulation. Acne is 
apt to make its appearance after a few doses of bromide in some patients. 

There is no other drug that at all approaches bromide in value for epilepsy. 
Nitrate of sodium, belladonna, zinc oxide or lactate (| to 5 grs.), borax (5 to 
10 grs.), nitro-glycerine (o^ to T -J F of a grain), and strychnine have all been 
used with more or less advantage when bromide fails. 

The question of surgical interference must depend upon the diagnosis ; 
in idiopathic epilepsy trephining or ligature of the carotids is hardly justi- 
fiable. If there is reason to believe that a tumour in the cortex exists, an 
operation may be considered (see p. 468). 

Infantile Convulsions. Eclampsia. — Infancy predisposes to those 
irregular nerve discharges which go by the name of ' convulsions ; or 
eclampsia. The undeveloped state of the cortical centres during infancy, 
and the consequent absence or imperfection of the controlling or inhibitory 
influences exercised by these centres in later life, allow the 'lower grade' 
centres to discharge their stored nervous force, when stimulated, in a way 
which does not occur in later years. The reflex actions exhibited by the 
brainless frog are more easily provoked and more vigorous than the reflex 
actions exhibited by a frog with the brain intact ; the higher centres appear- 
ing to exercise a controlling influence. 

While infancy is the time of life in which convulsions are most easily 
provoked, yet healthy infants do not become convulsed unless the stimulus 
is strong ; it is the delicate ones who are most likely to suffer, and especially 
those who have inherited neurotic tendencies. That hereditary influences 
play an important part there can hardly be a doubt, the infants of those who 
have suffered from epilepsy or who are of a highly nervous disposition 
certainly more often suffer from reflex convulsions than do the children of 
strong, healthy parents. The commonest predisposing cause, however, is 
rickets, thought in what way it acts is uncertain ; yet it is certain that all the 
tissues in rickets are badly nourished and built up, and the nervous system 
is no, exception to this : the nerve centres appear to be in a condition of 
unstable equilibrium, and are apt to discharge their nervous force in a pur- 
poseless and irregular manner. In the large majority of children who suffer 
from convulsions between the ages of six months and three years the signs 
of rickets are present. 

An anaemic condition, great exhaustion from any cause, as well as 
hereditary tendencies, predispose to convulsions during the whole period of 
childhood, but more especially during the first few months of life. 

The exciting causes of convulsions are mostly reflex : the irritation takes 
place at some distant part, the stimulus passes up to the nerve centre along 
some afferent nerve, giving rise to a discharge from a nerve centre or 
centres, the impulse travelling along the efferent nerves to the muscles. 

Reflex convulsions maybe said to be disorderly physiological reflex acts. 
In a normal reflex act the nervous mechanism is properly controlled and a 
useful movement takes place : in a convulsion there is an irregular and 
wasteful discharge of nerve force which fulfils no useful end. An infant's 
movements consist almost entirely of reflex acts of the simplest character, 
the nerve centres in action being of the ' lower grade ' group, situated in the 
spinal cord, medulla, and pons : such are the acts of swallowing, sucking, 



Infantile Convulsions 503 

crying, breathing ; in each case there is some form of irritation, or a stimulus 
acting on the nerve centre and transmitted to it by an afferent nerve, and an 
impulse is sent along an afferent nerve to a muscle or group of muscles, and 
.a definite, perhaps complex, act is performed. In morbid states of the nerve 
centres an afferent impulse calls forth a series of irregular and muscular move- 
ments, mostly in the form of clonic spasms, which may be limited to one 
group of muscles, or may implicate almost all the voluntary muscles in the 
body. Thus the presence of undigested curd in the stomach or bowels gives 
rise to acute pain or griping, and acts as a stimulus over a wide area, and 
some distant nerve centre, or perhaps many nerve centres, are thrown into 
activity. As a consequence of this the facial muscles may twitch, the legs 
be drawn up, the eyes roll about, the fingers be clenched ; there may be 
spasm of the respiratory muscles, and all the muscles of the extremities may 
be thrown into clonic spasm, or the infant suffers from whooping cough, and 
the spasm of the glottis passes into a general convulsion. Possibly the res- 
piratory muscles only may be involved, and spasm of the glottis and of the 
respiratory muscles may result. Dyspepsia or the presence of indigestible 
food is a fertile source of infantile convulsions in the newly born ; newly born 
infants when fed on artificial food frequently suffer from convulsions, which 
disappear at once when a wet-nurse is obtained. In making post-mortems 
on infants and young children who have died in convulsions it is no uncommon 
thing to find an overloaded stomach, and possibly pieces of meat and other 
indigestible food in the stomach. 

Dentition is another cause ; the pressure of the advancing tooth upon the 
gum, or the tension of the tooth in its socket, may, through the branches of 
the fifth nerve, produce general convulsions. Bronchitis or pneumonia may 
be the exciting cause, though the latter sometimes produces convulsions in 
consequence of the high fever that is present. 

The exciting cause of the convulsions may act directly on the centres 
themselves. Thus the onset of meningitis or any part of its course may be 
marked by convulsions ; an infant has a series of convulsions which are per- 
haps more or less one-sided, and when they cease it is noticed to be hemi- 
plegia, due, as we have already explained, to cerebral haemorrhage (see Cere- 
bral Haemorrhage). The acute stage of infantile paralysis may be attended 
with convulsions. Convulsions may be caused by chronic brain disease. 
A poisoned condition of blood may be the exciting cause ; thus a temperature 
of 104 or 105 is exceedingly likely to be accompanied by convulsions, the 
convulsions ceasing when the temperature falls, and being perhaps repeated 
when it rises again. Heat-convulsions are exceedingly apt to be fatal. A 
hypervenous condition of blood excites convulsions, as seen in infants born 
in a condition of asphyxia. The onset of some zymotic disease, as scarlet 
fever, or measles, is sometimes marked by convulsions. The commencement 
of influenza may be marked by convulsions. 

Symptoms. — The convulsive attacks vary greatly in their severity, and in 
the extent of the muscles involved. They may simply be slight jerky move 
merits of the head and neck, or a limb, or there may be slight twitchings of 
the muscles of the mouth or eyelids. The fingers may jerk and the thumbs 
turn in, the toes become flexed, movements to which the name of carpo- pedal 
contractions has been applied. Such slight convulsions are often spoken of 



504 Diseases of the Nervous System 

by nurses and parents as ' inward fits ; ' they are most common in young - 
babies with dyspepsia, or those who are suffering from distended bowels. 

A typical convulsion closely resembles an epileptic fit, but the stage of 
tonic spasm is usually shorter, while the clonic spasms or muscular twitch- 
ings are more prolonged and vigorous. 

The commencement of a fit is frequently marked by spasm of the glottis, 
so that the nurse thinks for the moment the infant is choking : at other 
times the rolling upwards of the eyeballs and twitchings of the facial 
muscles first call attention to the child. The face becomes pallid, the eyes 
are turned up so as to show ' the whites,' the limbs are extended and 
stiffened, the hands are clenched, the neck and back are arched, the jaw 
closes spasmodically : in a few moments the lips and face become of a 
bluish tinge from the respiratory spasm ; the tonic spasm quickly passes into 
clonic, the hands, feet, and face 'work' for a few seconds or more, and the 
child becomes quiescent and the fit is over. The child becomes uncon- 
scious during the fit, and may remain dazed for a few minutes to half an hour 
after. 

The fits may be severe, much of the type of a major epileptic fit, the 
tongue being held tightly between the gums or injured by the teeth, the child 
frothing at the mouth and becoming cyanosed, and remaining comatosed or 
drowsy for some time. On the other hand, the convulsions may be partial 
only : one side may be affected, the leg, arm, and side of the face twitching, 
or the laryngeal muscles or respiratory muscles alone may suffer. The fre- 
quency with which fits occur differs very much : a child may have a single 
one, and it may never be repeated ; or they may recur daily, or there may 
be a constant succession of fits for twenty-four or forty-eight hours, the child 
never becoming conscious. 

Some of the most severe convulsions we have ever witnessed have been 
in connection with whooping cough. The child begins to cough and forth- 
with a general spasm of the respiratory muscles takes place, with spasm 
perhaps of the muscles of the limbs. The child becomes dusky or pallid, 
and appears to be dead. Perhaps by the aid of artificial respiration it 
comes round, but such attacks are, we need not say, exceedingly fatal. 

Death may take place in the fit from spasm of the glottis. In other 
cases death seems to be caused in some way through the nervous system, as 
after death no evidence of asphyxia can be found. 

Convulsions in older children are indistinguishable from epileptic fits, and 
doubtless many of such cases for which no cause is found are really epileptic, 
or at any rate showing a tendency in that direction. 

Convulsions may be associated with idiocy or some mental defect, and 
it is not always easy to say to what extent the convulsions depend upon the 
presence of some cerebral lesion or malformation, or whether the mental 
defect is produced by the frequently recurring fits. It is not uncommon to 
see children of a few months to a year old who are frequently convulsed, 
and who are evidently idiots, not able to sit up or hold anything in their 
hands, and not recognising their friends. In these cases the prognosis, as 
far as the mental development is concerned, is grave, though the fits often 
become less frequent or cease as the infant develops. 

Prognosis. — This must always be uncertain, and naturally depends upon the 



Infantile Convulsions 505 

exciting causes. The first fit may prove fatal through spasm of the glottis ; 
on the other hand, it is common to get a history of children who as infants 
were constantly convulsed and yet have grown into comparatively strong 
children. Naturally much must depend upon what the exciting cause of the 
fit is : if it suggest commencing meningitis the prognosis is necessarily bad ; 
if there is hyperpyrexia and commencing pneumonia it is very grave. Con- 
vulsions following on some exhausting disease, as diarrhoea, are mostly fatal. 
Convulsions associated with laryngismus are always serious, and the prognosis 
must be very guarded. In those cases where the fits in young infants are 
frequently repeated it must be borne in mind that they may prove to be 
epileptic or associated with mental deficiency, and a guarded prognosis must 
be given. If there is reason to believe that the convulsions are due to 
dyspepsia or are symptomatic of rickets, the prognosis as far as the cerebral 
development of the child is good, but there is always the risk of its dying 
in a fit. 

Diagnosis. — The exciting cause of the convulsions may be difficult or im- 
possible to determine. Convulsions in infants shortly after birth may be 
due to a hypervenous state of the blood resulting from congenital heart 
disease or atelectasis, or to a meningeal haemorrhage, which has taken 
place during birth. If these can be excluded there is a strong probability that 
the fits are due to some digestive disturbance, especially if the infant is being 
artificially nursed. In infants over six months of age, with the symptoms of 
rickets, the fits are in all probability reflex and due to some alimentary 
troubles such as flatulence or griping in order to expel undigested curd ; but 
the possibility of their being due to commencing meningitis or to the presence 
of tubercles in the brain must always be borne in mind, even in the case of fat 
healthy-looking infants. Vomiting, irregularity or hesitation of the pulse- 
beat, or an unnatural softness of the abdomen would suggest meningitis. 
The possibility of the convulsions in infants being followed by a hemiplegia 
or a paralysis of one or more limbs must not be forgotten. In convulsions 
in young children the chest should be carefully examined and the tempera- 
ture taken, and the skin inspected to ascertain the presence or absence of a 
rash. In frequently recurring fits there is a possibility that the child may 
grow up mentally deficient, and a careful inquiry should be made as to the 
child's intelligence. 

The fact that infants often suffer from one-sided convulsions, or that the 
convulsion begins on one side, must not be taken to indicate that there is brain 
disease of the opposite side, inasmuch as reflex convulsions due to intestinal 
irritation may be one-sided in the first instance. 

Morbid Anatomy. — Convulsions per se leave no trace in the dead body. 
though usually there are the signs of death from asphyxia, the latter being 
most marked in those dying suddenly in strong health. The veins on the 
surface of the brain are full of dark blood, there are punctifonn or larger 
haemorrhages, and the brain may be unusually full of blood and wei from 
excess of cerebro-spinal fluid on the surface and in the lateral ventricles, but 
these conditions are due to death taking place through stasis of blood in the 
lungs and a consequent engorgement of the general venous system. The 
post-mortem examination of the state oi the cerebral vessels gives us no due to 
their condition, whether of engorgement or anaemia, during the tit itself ev 



■506 Diseases of the Nervous System 

such as are produced by venous obstruction. In many cases the autopsy 
throws no light on either : on the cause of the fit or the conditions which 
accompanied the fit. In others the appearances of commencing- bronchitis 
or pneumonia or acute intestinal catarrh may be found. Difficulties are, 
however, likely to be met with at the post-mortem in distinguishing between 
early pneumonia and the sodden and ©edematous lung often present which 
is due to the manner of death — namely, asphyxia from obstruction to the 
entrance of air into the larynx. 

In making an examination for medico-legal inquiries as to the cause of 
death, whether from a convulsion or from some other cause, great caution 
must be exercised in coming to a conclusion, especially in infants. An infant 
may have been 'overlain,' i.e. suffocated beneath the bedclothes in conse- 
quence of the mother going to sleep with the infant at the breast, the mother 
perhaps alleging that the infant had died in a fit. In both cases the after- 
death appearances may perhaps be much alike — namely, those of death from 
asphyxia. In many cases, however, a distinction may be made between a 
rapidly produced asphyxia, as in death from a fit, and a more slowly produced 
asphyxia, as in slow suffocation beneath the bed-clothes : in the former the 
lungs are simply gorged with dark fluid blood, in the latter case the lungs 
are sodden and cedematous, containing a large amount of frothy fluid. In 
any case where the tongue is held between the teeth and has been injured, 
and there are signs of rickets, the lungs gorged with dark fluid, and the veins 
on the surface of the brain overfull, there is a strong probability that the 
child has died in a fit. It must not, however, be too hastily assumed that 
a convulsion has not been the cause of death, because the typical signs of 
asphyxia are not present ; death appears to take place in some cases pro- 
bably through the nervous system, before asphyxia takes place. 

Treatment. — The treatment of convulsions must necessarily be chiefly 
directed to removing the cause. During the convulsion itself, if there is a 
high temperature (io4°-io6°), no time should be lost in placing the infant 
or child in a tepid bath and pouring cold water over the child and into the 
bath in order to lower the temperature, which is probably exciting the con- 
vulsions, and it may be also necessary to give antifebrin or quinine. In reflex 
convulsions in a robust child, especially if there is colic or abdominal dis- 
turbance, a warm bath, or a mustard bath so as to redden the skin, is likely 
to prove of service, or the child's socks may be wrung out of mustard and 
water and placed on the feet, or hot flannels may be placed on the abdomen. 
If there is reason to suppose the convulsions are due to cerebral disease, 
or the convulsions come on at the end of an exhausting illness, the warm 
bath is not likely to be of any service and may be injurious. If the child 
has taken any indigestible food, which is lying in the stomach or in the 
bowels, an emetic or one or two grains of calomel should be administered 
according to the effect desired. If the gums are swollen and tender, an 
incision, or simply scarifying them, will often do good. If there is otitis, it 
may be well to puncture the membrane. 

The inhalation of a few drops of chloroform or nitrite of amyl will 
usually check the violence of the convulsive spasms, and should certainly 
be tried if the convulsions last any time or are violent. Of medicines 
which diminish the irritability of the nervous centres, the bromides, chloral, 



Tetany 507 

and belladonna hold the first place. Bromide of potassium or sodium must 
be given freely if the convulsions recur time after time. If the child can 
.swallow, 3 to 5 grains may be given to an infant of six months to a year old, 
and repeated every hour or two for several doses, according as the convul- 
sions are piesent or not ; smaller doses, less often repeated, should be given 
if improvement takes place. No harm is likely to ensue by pushing the 
bromide. The bromide may be given by the rectum if necessary. Chloral 
is in some cases more useful than bromide, but it must be used more 
sparingly; a two- or three-grain dose maybe given to an infant under a year, 
and repeated in an hour if the convulsions are still present ; but its soporific 
effect must be watched. Chloral, we are inclined to think, is more useful 
than bromide in convulsions due to colic or whooping cough. Bromide, 
chloral, and cannabis indica are often given in combination with advantage 
in convulsions. Cold to the head in the form of ice or wet cloths should 
be used if meningitis is suspected, and the infant should be carefully pro- 
tected from all excitement. 

Convulsions in infants a few weeks old, who are artificially fed, are due 
in the large majority of cases to dyspepsia, and no time should be lost in 
procuring a wet-nurse, or at any rate in giving the infant the most suitable 
food that can be proem ed. The bromides will have but little effect in stop- 
ping the convulsions as long as acute dyspepsia or colic is present. 

Tetany 

The term ' tetany' is applied to a form of tonic spasm mostly affecting 
the extremities, which, like spasm of the glottis, consists in a reflex con- 
traction of a group of muscles, the result of irritation in some distant 
part. Tetany may affect both children and adults, though it is commoner 
before the age of three years than after this period. It is frequently asso- 
ciated with rickets, in this respect resembling convulsions and laryngeal 
spasm ; it frequently occurs in connection with laryngismus. It rarely 
makes its appearance in healthy children, but in those who have suffered 
from some exhausting disease, especially some affection of the alimentary 
canal, as diarrhoea or acute enteritis ; prolapse of the rectum may be an 
exciting cause. Difficult dentition appears to be an occasional cause. One 
of the most severe cases we have seen was associated with a fatal attack oi 
acute enteritis. It has been observed in rare instances as an early symptom 
in pneumonia and other diseases, in this respect resembling convulsions, 
and tonic contraction of the muscles at the back of the neck. It has some- 
times prevailed epidemically among school-girls, but in such cases the mus- 
cular contractions were no doubt due to hysteria. 

Symptoms and Course. The attacks consist in spasms of the muscles Oi 
the extremities, more especially of the forearms and feet. There is no loss 
of consciousness, and usually no spasm of the facial muscles, though there is 
mostly an expression of pain on the face when the cramps come on. In the 
severer cases the arm is adducted at the shoulder and fixed to the side, the 
elbow is flexed at right angles, the forearm pronated, the wrist flexed, the 
thumb turned in, while the fingers are in the position of interosseous spasm, 
or the hands may be clenched o\ or the thumb. If the former, the metacarpo- 
phalangeal joints are flexed, while the other phalanges are extended. 



508 Diseases of the Nervous System 

In the lower extremities the foot is in the position of talipes equinus or 
equino-varus, the plantar surfaces being hollowed out and the toes bent. 
The knees may be semi-flexed and the thighs adducted. The muscles of 
the calf are hard and rigid, feeling as if gathered up into a ball (see fig. 102). 

There is usually cedema of the dorsum of the feet and hands, from inter- 
ference with the venous circulation. 

The contractions are evidently painful ; the infants scream when they are 
handled or interfered with ; the spasms may intermit, but usually last a 
considerable time. In rare cases, notably those recorded by Cheadle, the 
muscles of the face are thrown into spasm ; in other cases the muscles of 
the jaw, abdomen, neck, and back have been affected. More commonly the 
spasm is confined to the hands and feet, or the hands only may be affected. 
The spasm lasts from a few minutes to many hours or even days, then dis- 
appearing and perhaps appearing again. Most of the muscles of the body 
are in a condition of irritability, especially those of the face. This is 




Fig. 102.- Tetany affecting limbs, also muscles of neck. 

evidenced by the readiness with which they contract when the facial nerve 
is irritated. If the finger be passed smartly over the angle of the mouth, 
a sharp contraction of the levator follows ; or the finger is brushed across 
the outer side of the orbit, and a contraction of the orbicularis ensues. This 
' facial phenomenon,' however, is not peculiar in tetany. 1 

The same irritable condition of muscles can sometimes be demonstrated 
by compression of the large nerve trunks of the arm, which may give rise to 
muscular spasm in the hands and fingers. This is sometimes referred to as 
'Trousseau's phenomenon.' 

Tetany never threatens Yifefler se, as it only affects the muscles of external 
relation, though the child may die from the effects of the gastro-enteritis, of 
which the muscle cramps are only symptoms. The only case which ter- 
minated fatally, which we have seen, was the case, referred to above, of a 
boy aged six years, who died in a few days from the effects of a gastro- 
enteritis ; the principal symptoms were constant vomiting, cramps in the 
stomach, and tetany of both upper and lower extremities. The post-mortem 

1 J. Loos, M.D., Wiener kli?i. Wochenschr. No. 49, 1891 ; ' Laryngismus,' Dr. W. 
Gay, Brai)?, January 1890. 



Nystagmus 509 

showed the brain and cord to be normal to the naked eye ; the mucous 
. membranes of the stomach and intestines were injected, and evidently in a 
state of acute catarrh. In another case, somewhat similar, Hadden could 
find no changes in the cord. 

Tetany is apt to return from time to time after a considerable interval ; 
this may be noticed in cases received into hospital : these mostly get well 
quickly and go home, but in another week or two are as bad as ever. 

Diagnosis. — Tetany may be mistaken for cerebro-spinal meningitis, but it 
can only thus be mistaken when the constitutional symptoms accompanying 
the tetany are severe. In tetany there is an absence of cerebral symptoms 
as well as vomiting and fever. In tetanus the spasm of the masseters is an 
early symptom ; it is absent in tetany, or comes on late in the attack. 
The position of the fingers is different in the two diseases. In girls or 
•older boys hysterical contraction might stimulate tetany, but the former 
usually affects one limb, or an arm and a leg only, while the latter is always 
bilateral. 

Treatment. — The treatment must be directed in the first place to the 
exciting cause. A dose of calomel or grey powder should be given if there 
is any gastro-intestinal disturbance or undigested food lodging in the 
intestinal tract, and the greatest care taken to give only the blandest food. 
Warm baths may be given to relieve the spasm, and hot laudanum fomen- 
tations applied to the hands and feet. Bromide of potassium is likely to 
relieve the symptoms if given in full doses. Chloral, belladonna, digitalis, 
and Calabar bean have all been used with benefit. Cheadle found the ^ 
to I grain dose of Calabar bean of use in one case. 

OTystagmus. — Nystagmus is common during both infancy and childhood 
and accompanies very different conditions. It usually consists in short, 
rapid oscillations of the eyeballs in a lateral direction, the head sometimes 
moving also. In some cases the ocular movements are vertical instead of 
lateral. It may be present in congenital cataract, tumours of the brain, 
hydrocephalus and hereditary ataxia ; but it is also present in children who 
are not suffering from any organic disease. It maybe present in some forms 
of clonic spasm of the neck. 

Head-nodding- and Head-shaking, going on constantly as they some- 
times do in infants and young children, are the result of a clonic reflex 
spasm of the sterno-mastoids, either both acting together and making a 
nodding movement, as in expressing assent, or acting alternately and shaking 
the head as if expressing dissent. The movements may be constant or 
intermittent, perhaps ten or twelve times an hour. Nystagmus may be 
present. These curious spasmodic affections appear to be allied to laryn- 
gismus. Dr. Gee records a case whose brother died of laryngismus, and in 
one case of 'head-nodding,' mentioned by A. Baginsky, the child suffered 
later from convulsions and laryngismus. Head-shaking in older children 
Dr. Gee connects with epilepsy. The prognosis is good ; like laryngismus, 
these affections appear to be due to some reflex irritation in the alimentary 
canal or to dentition. 

1 Head banging ' in children has been described by Dr. S. Gee. It con- 
sists in a peculiar habit, to which some children are liable, of turning over on 
to their face at night and banging their heads into the pillow. Dr, Gee 



5 1 o Diseases of the Nervous System 

records three cases : two of these were two and a half years of age, and one 
was five years. One child used constantly, nearly all night, to bang his 
forehead into his pillow. No cause was found to account for this strange 
habit. It appeared very intractable, but one child much improved whilst 
living in the country. 

Hysteria.— Functional nerve disturbances, in the form of sensory de- 
rangements, paresis, contractures, or eclampsia, are by no means uncom- 
mon in children. Hysteria when it occurs during early life mostly affects 
girls, but it occurs also in boys ; the approach of puberty is the most common 
period. 

A tendency to hysteria runs in families, and is transmitted from parents 
to children, but the injudicious way in which children are often brought up, 
their weaknesses pampered and their ailments intensified by an injudicious 
sympathy, often tends to aggravate an hereditary disposition to nerve disorders. 
While it most frequently happens that hysterical children come of neurotic 
families and belong to the well-to-do classes, yet such children may be 
found in country districts among country folk, where neurotic tendencies 
might be least expected. ' Fasting girls ' who have had a temporary notoriety, 
' cataleptics,' and religious maniacs have been found in cottage homes and 
among surroundings that one would have supposed were little likely to 
foster hysterical affections. 

Hysteria in its milder or severer forms is often associated with other 
diseases, such as epilepsy, chorea, and various mental affections ; it may also 
be engrafted on to organic brain disease, such as meningitis or some spinal 
affections. Hysterical phenomena are rare before the age of six years and are 
most common about puberty, especially in those cases where menstruation 
has failed to become established. 

Symptoms. Sensory Disturbances. — Perhaps the most common form 
of hysteria in girls is hyperacsthesia ; there is a complaint of tenderness 
or pain which cannot be accounted for except by a neurosis. There is some 
local tenderness about the spine or one of the joints, especially the hip, the 
girl screaming with pain when the joint is moved ; the thyroid gland or 
front of the larynx is sometimes hypersensitive. Headaches are very common : 
these may be frontal or occipital, or may take the form of the ' clavus ' of 
adults. Hysteria is apt to mimic various diseases which are normally 
accompanied by severe pain, such as peritonitis, pleurisy, rheumatism ; it 
must, however, be always borne in mind that there may be some actual 
disease present, and that the sensory disturbance is only an exaggerated con- 
dition of what would normally exist. 

Anaesthesia is much less common in children than hyperesthesia ; but 
hysterical hemiansesthesia, in which the special senses are involved, occa- 
sionally occurs. Sleeplessness is not uncommon, the patients asserting that 
they cannot sleep, and only perhaps dozing off when it is time to get up. 

Motor Disturbances. — Paralysis, or rather paresis, is common ; the larynx 
is perhaps most frequently affected, but paraplegia is not infrequent. Hys- 
terical aphonia in girls has the same characters as in adults : there is loss 
of voice, the patient always speaking in a whisper ; sometimes the voice is 
entirely lost. 

Paraplegia may come on suddenly after a convulsion, or the legs may 



Hysteria 5 1 1 

gradually give way under the child, until she can no longer stand, and is 
therefore confined to bed. There may be loss of sensation, but in our ex- 
perience this is uncommon. The loss of power is never complete : the 
patient moves the legs in bed, and often some attempt will be made to 
stand with help, or she may draw up the legs to prevent them touching the 
ground, and will sink to the ground rather than support her own weight. 
The electrical reactions are normal, and usually the knee-jerk is also normal, 
and there is no ankle-clonus. In other cases, more especially those which 
have lasted some time, there is more or less tonic contracture of the legs ; 
the hip and knee-joints are semiflexed, and the foot takes the position of 
equino-varus. In this condition, if the spasmodic contraction is not too 
marked, there may be excessive knee-reflex, and ankle-clonus may be 
present ; if there is marked contracture, no knee-reflex can be obtained on 
account of the rigid contracture of the opposing muscles. The contracture 
is present during sleep, but usually goes off when the patient is under 
chloroform. 

In hysterical paraplegia there is no incontinence of urine or faeces ; this 
is certainly the rule, but retention of urine will occur, and in some conditions, 
such as ' hysterical chorea,' both urine and faeces will at times be passed 
involuntarily. We have seen on several occasions girls who were suffering 
from hysteria, simulating hip disease or peritonitis, pass their water in 
bed, so that the bed and linen have been saturated with stinking urine, rather 
than use a bed-pan, as they were afraid of being moved on account of the 
pain it caused. In such cases bedsores may form and the patient become 
emaciated. 

Convulsive Attacks. — These are of the usual hysterical type. There 
is a fit of screaming or crying or violent laughter, tonic contraction of the 
muscles, more especially of the back, so that opisthotonos is produced ; the 
arms and legs are dashed about and the head perhaps made to strike the 
pillow or bed violently. The patient remains conscious during the attack, 
and she rarely injures herself, and the tongue is not bitten. The so-called 
' hysteroid ' fits have already been referred to (p. 499). 

Mental Symptoms. — Hysteria is closely allied to some forms of insanity, 
and various forms of hysterical insanity occur in girls about puberty. One 
of the commonest of these is a refusal of food. The girl's appetite becomes 
poor, she gradually grows thin, and this excites the sympathy and alarm of 
her friends. The morbid craving for sympathy becomes intensified. She 
resists all their entreaties to take food, and clenches her teeth when it is 
offered, or only takes the smallest quantities, and frequently is guilty of 
deceit, concealing food in her clothes. She gradually wastes till she becomes 
a perfect skeleton, the skin is rough and harsh, the abdomen flattened, and 
the breath foul. Bedsores not infrequently form. In other cases, though re- 
fusing all food at meal times, she will surreptitiously obtain cakes or confec- 
tionery, which she will cat readily. In some of these cases there is melan- 
cholia or eclampsia. Morbid conscientiousness is sometimes present : the 
girl perhaps takes away marks from herself at school, or accuses herself oi 
having told untruths or ofhaving stolen her schoolfellows' things. 

Vomiting and spasm of the pharynx are not uncommon, one or other 
of these may be present formonths and lead to wasting. Usually the food 



5 1 2 Diseases of the Nervous System 

returns at once or within a few minutes of taking. Sometimes the food will 
be retained, but there is nausea and retching. 

Diagnosis. — The first step in diagnosis is necessarily to attempt to exclude 
organic disease, which hysteria so often mimics. In sensory hysterical dis- 
orders, such as headaches, and in various forms of paralysis, the question 
is whether or not there is cerebral or spinal disease. Probably the com- 
monest mistake is to assume that organic disease exists when the condi- 
tion is one of hysteria only ; but, on the other hand, we have known the 
symptoms in the early stages of a cerebral tumour attributed to hysteria. It 
is often necessary to wait before a definite diagnosis can be arrived at. But 
it is always necessary to bear in mind that an organic lesion may exist and 
yet undoubted hysterical symptoms be present. 

Treatment. — The treatment of hysteria in its various forms is principally 
moral. The management of the patient must pass from the parents to a 
suitable nurse, or, better still, the patient should be removed to hospital or into 
lodgings away from her friends. If once the child is under firm control, is 
deprived of the morbid sympathy it craves for, and is at the same time en- 
couraged to put forth all its voluntary power, an improvement in its condition 
will immediately begin. In cases of paralysis, in addition to isolation from 
the parents and all sympathising friends, massage and faradisation are of 
much advantage. The patient must be made to use the weakened limbs in 
moderation, and encouraged to believe that they will get entirely well. 

In less severe cases change from city to a healthy country life is of great 
importance. Life at a farm with its many outdoor attractions and occupa- 
tions is perhaps the best adapted for hysterical children. Effort must be 
made to interest them in many things outside themselves in order to break 
the vicious habit of dwelling inordinately on their own feelings and ailments. 
In many of these cases the general health is poor and menstruation delayed. 
In such, iron in the form of bromide of iron, as in Fletcher's syrup, is useful, 
while the -bowels should be regularly acted on by small doses of aloes, or some 
mineral water such as Rubinat or Hunyadi Janos. 

Headaches. — Children, especially girls of seven years of age on to 
puberty, are very liable to headaches, sufficiently severe to lay them up for 
part of a day or perhaps longer. These headaches may arise from various 
causes, and it is important to try, if possible, and ascertain their origin ; 
diagnosis is frequently by no means easy, as pain is referred to the forehead 
in many different morbid states and conditions. Frontal headache is by far 
the commonest form of reflected pain. It is important in the first place to 
exclude hypermetropia as a cause of frontal headache. Straining the accom- 
modation of the eyes, especially when the subject is below par, may give rise 
to frontal headache, aching being referred to the eyeballs, while at the same 
time, when an attempt is made to read, the letters run together and the 
eyes easily water. A diagnosis is easily made with the ophthalmoscope, 
examining the retinal vessels by the direct method, as well as by the use of 
test types. 

Headaches are very common in rapidly growing children, who are, to 
use an ordinary expression, ' outgrowing their strength.' Such headaches 
may be due merely to weariness or to the irritable state of the nerves which 
comes on when over-tired or fagged ; or they may be due to amemia or 



Headaches 5 1 3 

dyspepsia. The latter is probably the most frequent cause. The appetite 
may be good or capricious, more food is taken than the digestive organs can 
cope with, and dyspepsia or a subacute gastric or intestinal catarrh is the 
result. A sick headache is complained of, the child looks heavy and dark 
about the eyes, there is nausea or actual vomiting, perhaps some fever, and 
It takes a day or two to regain the ordinary state of health. Headaches due 
to overwork of the eyes and brain are especially common in schoolboys and 
girls when preparing for examinations and taking too little exercise and re- 
creation. With the headache there is often sleeplessness at night, anaemia, 
and more or less dyspepsia. There is usually no difficulty of diagnosis here, 
as the history of the case will render its nature plain. 

There is a form of headache which is by no means uncommon, which is 
distinctly neurotic, and which does not appear to be connected in any way 
with dyspepsia, sluggish liver, overwork at school, or organic disease. The 
child is usually a girl of ten or twelve years of age, who suffers with a severe 
headache, often accompanied by sickness, once or twice a week, perhaps 
•oftener, which comes on at irregular times, and is sufficiently severe for her 
to take to bed or to lie on the sofa for most of the day, and to incapacitate her 
for all work or play. Such headaches are made worse by noises and exer- 
tion; at times there is violent sickness or retching, and perhaps giddiness in 
the erect posture. The bowels are usually constipated, the tongue clean, and 
in the intervals between the attacks the child is in good health and able to go 
to school and take moderate exercise. The causes of such headaches are very 
difficult to discover ; a tendency to such is often hereditary, and, while worse 
■during the period of puberty, the tendency may remain throughout life. 
They are often very obstinate, and medicine fails to relieve as long as the 
patient remains at home, leading a sedentary town life ; they are almost 
always better during the holidays spent away at the seaside, or whilst lead- 
ing a healthy country life, but recur again when a return is made to town 
life, with school and the ordinary home routine. 

In some other cases the headaches are more distinctly hysterical, the 
pains being described as of a ' shooting ' or l boring ' character, and coming 
on when the spirits are depressed or when there is some unpleasant duty or 
distasteful study to be undertaken. On the other hand, all headaches are for- 
gotten if the patient is roused by some excitement or the prospect of some 
unusual pleasure. When the headache is present, the patient demands the 
sympathy of all her friends, and is apt to lapse into a chronic invalid, 
expecting to receive the commiserations and attentions of the whole house- 
hold. She objects to exertion of any kind ; the least noise or loud talking 
brings on the headache. The appetite perhaps becomes poor, she becomes 
thinner, and the whole health suffers, or, on the other hand, in some cases the 
appetite is not affected. These hysterical headaches are commonest at or 
about puberty, when menstruation is commencing, but they may be present 
in boys and in girls of nine or ten years of age. 

The most important question in connection with diagnosis is with regard 
to the presence or absence of organic disease. Are tubercles forming in the 
meninges of the brain ? Is there a cerebral tumour, or are the headaches 
cither reflected from the digestive system or purely nervous in character? 
The diagnosis between cerebral disease and functional disease is usually not 

1 L 



514 Diseases of the Nervous System 

difficult if the history given by the friends can be relied upon, or if there is an 
opportunity of watching the patient for a few weeks. The headache accom- 
panying the early stages of tubercle of the meninges is associated with 
irritability, wasting, hectic fever, loss of appetite, shivering, and cough ; and a 
few weeks more or less will almost certainly see developed more marked 
cerebral symptoms, such as squint, vomiting, and involuntary passage of 
faeces. The headache due to cerebral tumour is mostly constant, though worse 
at times than at others ; it is always made worse by movement ; there are 
erratic and apparently causeless vomiting and optic neuritis. 

Treatment. — The treatment of headaches is naturally directed to removing 
the cause. The treatment of headaches of rapidly growing children will 
mainly consist in the avoidance of over-exertion or fatigue, a very moderate 
amount of brain-work, a healthy country life, and a careful regulation of the 
diet. The digestive organs are probably being given more work than they 
are able to perform, a gastric or intestinal catarrh is set up, and the disordered 
state of digestion is expressed by a frontal headache. Vomiting in these 
cases nearly always relieves the headache ; if it does not take place, perhaps 
there may be feverishness, nausea and headache for a day or two. When 
these headaches are coming on, the simplest and best remedy is an emetic 
such as a teaspoonful or two of ipecacuanha wine, to be followed by a little 
judicious starvation or the lightest possible diet for a few days. For the 
avoidance of such sick headaches meat should be allowed in only moderate 
quantities, it must be well cut up and masticated slowly, and care should 
be taken to regulate the bowels from time to time with some effer- 
vescing citrate of potash, Rubinat or Carlsbad water, before breakfast. In 
the neurotic forms of headache, arising independently of digestive derange- 
ments, the treatment is often very unsatisfactory. When the attack comes 
on, and is evidently severe, bed is the best place, with a wetted handkerchief 
to the head in the hope of getting the child to sleep ; coffee, effervescing 
citrate of caffein (1 to 2 grains of the pure salt), monobromide of camphor 
(1 to 2 grains), ext. guaranae liq. (10 to 15 drops), ext. cannabis indicae, or bro- 
mides are often beneficial. Antipyrin (2 to 5 grains) has been used with 
good effect. In the intervals between the headaches the most important 
treatment relates to regulating the bowels and to insisting on a simple but 
nutritious diet. In some cases good has followed the entire avoidance of 
butcher's meat (Haig). A healthy country life or change of scene is often 
of the greatest service and generally effectively cures, for a while at least. 
In hysterical headaches the patient should be encouraged to take an active 
interest in some work or play. 



CHAPTER XXII 

DISEASES OF THE NERVOUS SYSTEM — continued 

Speech Anomalies 

DURING the first year of life the infant is unable to express itself by means 
of intelligent speech, nor does it make much progress in the understanding 
of spoken words. Yet from the earliest months it makes its wants known 
in a sort of way by the tone and manner of its cry ; it can in this way ex- 
press pleasure or grief, and it can interpret to some extent the meaning of 
what is said to it by the tone of voice in which the words are spoken and 
the gestures by which they are accompanied. A cry is the first sound 
uttered by the infant, and crying is indulged in pretty freely to express any 
form of discomfort or a feeling of neglect, and at first with but little variation. 
Within the first two months (five weeks, according to Preyer) variations in 
the tone and strength of the cry occur, indicating acute pain or hunger or 
impatience. Later still the cry becomes more distinctive and expressive, 
and the cry of anger or disappointment may be distinguished from the cry 
of hunger. Smiling may be observed by the end of the second month or 
earlier (twenty-third day, Preyer), but really noisy laughter is not heard till 
several months later. Other facial expressions, such as frowning, rage, 
sulkiness, are noted later in the first year. From the earliest months the 
infant 'babbles' or 'crows' when pleased or in a good humour. It seems 
to take a pleasure in exercising its organs of speech, in much the same way 
that it derives pleasure from lying on its back and kicking vigorously in an 
aimless sort of way. Both consonant and vowel sounds are produced in 
great profusion, but in an irregular and inco-ordinate fashion. Preyer 
noticed that in one of his babies all the vowel sounds and all the consonant 
sounds were used during the first seven months except ia, s, s,f, and s/i ; all 
the latter were postponed till the second year. By the end of the first year 
some of the easier consonant sounds, such as mam-mam, da-da, (fader, nana, 
are repeated in a meaningless sort of way, but before long they are applied to 
persons and things. Some of the earliest sounds acquired are those made by 
domestic animals, and the child quickly uses the sound to name the animal. 
During the second year the vocabulary increases fast, the child quickly 
imitating and repeating the words it hears, so that by the end of the second 
year it not only uses a number of words, but can string a few nouns and 
adjectives together, and has learned the meaning of short phrases. Thus 
we find such short sentences used as ' /Cennie come in mt \' or 

k Kennie no liky pudding? At this period, and for the next year or two, 
words arc indistinctly or improperly pronounced, with a tendency to clip 

t i 2 



5 16 Diseases of the Nervous System 

them short or to drop consonants. Some consonants present greater diffi- 
culty to the young child than others, and are constantly dropped out of 
words ; thus s, especially when it precedes another consonant, is omitted, 
as coot for school, kwek for squeak, no for snow. Difficulties often arise 
with the aspirate dental as th and sh : Ruth becomes Roof; the vibratory 
consonant r is a great stumbling block, and the distinct pronunciation of it 
is, perhaps, never acquired : grub is apt to become gwub, and roof woof 

Some children are more backward in talking than others, and are at the 
same time behindhand with walking and cutting their teeth, and it is only 
after the end of the second year is passed that they begin to make progress. 
This frequently happens with rickety children, or with those who have had 
some serious disease to contend with. Other children not only do not begin 
to talk when the usual time arrives, but as months and years go on make no 
attempt, or their articulation is indistinct and imperfect for their age. In 
another but smaller class the child learns to talk fairly well or imperfectly, 
then an illness comes on and it loses the power of speech. The principal 
causes of imperfection, or absence, of speech may be tabulated thus : 

i. Deaf-mutism. — The infant may be born wholly or partially word-deaf, 
or may become so from the effects of disease. The child is mute because it 
is deaf. 

2. There is some physical defect in the formation of the mouth or vocal 
apparatus. 

3. The child may be feeble-minded, or have some defect of the brain. 

4. There may be aphasia associated with right hemiplegia or due to some 
functional cause. 

5. The difficulty of speech may be due to stammering or hesitancy of 
speech. 

1. Deaf-mutism. — Deaf-mutes are those who cannot speak because they 
cannot hear : the deafness may be due to congenital defect, or they may be- 
come deaf through illness before they have learnt to talk ; as a rule, if the child 
becomes deaf before he is seven years of age, dumbness will result. The 
congenital variety appears mostly to be the result of hereditary taint, con- 
genital deafness having occurred previously in the same family. It is doubtful 
if the marriage of cousins has anything to do with it. The morbid ana- 
tomy is very uncertain, as there are but few post-morte?n records of such 
cases ; in some cases there is reason to believe that congenital deafness is 
the result of inflammation of the internal ear during intra-uterine life. How 
early is it possible to detect deafness ? The diagnosis is necessarily very 
difficult during the first few months of life, especially when we remember 
that congenital deafness is rarely complete, the ringing of bells, whistling, &c, 
being heard when the ear is quite incapable of detecting articulate sounds. 
' Word-deafness ' is congenital as well as the result of disease. During the 
first few weeks after birth the healthy infant gives no response or signs of 
recognising sounds, but loud noises will wake it up. It is only during the 
third andfourth months that the infant appears to recognise sounds and voices, 
but, as some infants are more backward than others with regard to percep- 
tions, it is only after six months of age, or from that to a year, that a definite 
knowledge can be come to with regard to deafness. When the infant is a 
year old, and has never uttered an articulate sound, while it shows no want 



Defects in Speech 5 1 7 

of intelligence in other ways, and its muscular power and growth is in ac- 
cordance with the normal standard, there is strong reason to believe that 
its speech defect is due to deafness. The diagnosis between a failure to 
speak due to partial deafness or word-deafness and failure on account of 
mental feebleness is often extremely difficult, perhaps, in certain cases, for 
a time impossible, in the absence of other signs of mental defect. 

Acquired Deaf-mutism. — When a child under seven years loses its 
hearing in consequence of disease, its speech becomes indistinct and more or 
less unintelligible, and it loses the power of speech altogether, either quickly 
or gradually, according to its age and intelligence. The loss of speech will 
necessarily depend to some extent upon the amount of deafness. According 
to Hartmann it is possible, if the child is intelligent, and great care is taken 
to correct its mistakes in talking and to induce it to talk, that speech may be 
retained. 

The lesion which commonly produces deafness is an inflammation of the 
labyrinth, either idiopathic or secondary to meningitis, scarlet fever, typhoid, 
or whooping cough. The difficulty of distinguishing between acute otitis and 
meningitis has already been pointed out (p. 450), and consequently the 
extent to which deafness is produced by one or the other is uncertain. 
Attacks of cerebro-spinal meningitis undoubtedly frequently produce deaf- 
ness, as does also scarlet fever. In this country scarlet fever plays a more 
important part than other diseases in destroying the auditory apparatus. 
Hartmann believes that an inflammation of the labyrinth and consequent 
injury to the terminal apparatus of the auditory nerve, and not suppuration in 
the middle ear, is the cause of deafness ; though the latter frequently takes 
place, it is not necessarily present. A naso-pharyngeal catarrh seems to be 
an occasional cause of labyrinthine disease. 

The hearing power of deaf-mutes is usually tested with a bell and 
tuning-fork, the two ears being tested separately. Statistics collected by 
Hartmann show that in 865 cases of deaf-mutism in different institutions 60 
per cent, were totally deaf, about one-fourth (24-3 per cent.) heard sounds 
such as the ringing of a bell, while 15 per cent, heard words or vowel sounds 
when pronounced loudly close to their ears. 

2. Physical Defects in the ZVIouth. — Parents not infrequently bring a 
child to consult a medical man with regard to his backwardness or indis- 
tinctness in speech, which is attributed to his being tongue-tied or to some 
deformity of the mouth or palate. In the majority of such cases no physical 
defect can be detected, the defect being rather in the nervous mechanism 
of speech. It is quite conceivable that a more than usually attached fraenum 
may be present and interfere, however slightly, with the movements of the 
tongue, and the dentals, t,d, s, are badly prone unced. 1 A highly arched or 
deformed palate may render speech imperfect, the child speaking like one 
with cleft palate ; but it must not be forgotten that weak-minded children 
may have high palates and the defective speech be due to mental feebleness. 
Defective speech is also present in those with large tonsils and post-nasal 
adenoids ; there is a characteristic ' stuffiness ' about the voice, and difficulties 
with the resonants /;/, //, ;/<,'", inasmuch as in the pronunciation o\ these the 

1 See ' Some Forms of Defective Speech,' Warrington Haward, Lancet, vol. i. p. in. 

1887. 



5 1 8 Diseases of the Nervous System 

nasal chambers act as a resounding cavity. Paresis of the soft palate may- 
be present, especially after diphtheria, the voice having a nasal twang and 
difficulty being experienced in pronouncing the explosive labials^ and 6, as 
the air escapes into the nasal cavity, the soft palate failing to act. 

3. Mental Defect. — Perhaps the commonest form of defective speech is 
that connected with the nervous mechanism. The child perhaps appears per- 
fectly intelligent and bright, no defect can be discovered in the mouth, yet 
his pronunciation of certain sounds is defective, as if he used his tongue or 
lips imperfectly, or had not them under perfect control. He may have 
especial difficulty with the dentals, such as /, d, s, a, and consonants which 
require great precision in the use of the tongue ; or the difficulty may be 
with the labials, as^, b,f m ; or he may lisp in an exaggerated manner. All 
degrees of difficulty of speech may exist : it may be so marked that the child 
avoids conversation as much as possible, and expresses his assent or his 
wants by signs. This form of difficulty of speech is often hereditary. It is 
possible that in some of these cases the hearing is at fault and the child 
suffers from partial word-deafness, in a similar way to a child suffering from 
colour-blindness, or a faulty development of the co-ordinating motor centre 
of speech. Some children talk a sort of gibberish which perhaps their 
brothers or sisters understand, but no one who has not been with them a 
great deal can make out. 1 

If, however, instead of imperfect speech the child of five or six years of 
age does not talk at all, there is probably some mental defect, the child fail- 
ing to understand what is said, or although it may understand the speaker, 
yet there is a failure in the process of converting thoughts into words. 

4. Aphasia. — Children, like adults, may suffer from aphasia due to 
organic disease, or from a functional aphasia. In the former the aphasia 
may be the consequence of embolism of the left middle cerebral artery, and 
be associated with a right hemiplegia, or a tubercular tumour may compress 
the left third frontal convolution. 

Functional aphasia is not uncommon and occurs usually after exhausting 
fevers ; as, for instance, in typhoid after the febrile stage is passed many 
months may elapse before the child speaks. It may occur after pneumonia ; 
thus a child of two and a half years suffered from inflammation of the lungs 
in October ; his mother said his talking left him while getting better. He 
didn't speak a word till the following April, when he said ' Drink ;' the follow- 
ing month he began gradually to talk again. (See also case, p. 490.) 

The power of speech is lost suddenly at times in consequence of a nervous 
break-down. Dr. Langdon Down records the cases of two brothers, who had 
spoken well and understood two languages, completely losing the power of 
speech at the period of the second dentition. 

5. Stammering- occurs occasionally before the period of the second den- 
tition ; it is often hereditary, and is always worse during a period of ill health. 
Boys are far more commonly affected than girls. It is especially apt to 
supervene in boys who are overworked at school, and who inherit neurotic 
tendencies. 

Treatment of Defective Speech. — The treatment necessarily depends on the 

1 See Dr. W. B. Hadden ' On Certain Defects of Speech in Children,' Journal of 
Mental Science, January 1891. 



Defects in Speech 5 1 9 

cause of the defective speech. Surgical treatment maybe required in the 
first place : enlarged tonsils must be excised and post-nasal adenoids removed, 
defects in the hard or soft palate must be remedied as far as possible by sur- 
gical and mechanical means. Special instruction in articulation, especially 
directed to the difficult sounds, must then be practised. For this purpose 
the teacher faces the pupil, showing him by exaggerated movements of his 
own lips, tongue, or larynx the positions they should assume to form the 
desired sounds, and practising the pupil in these movements. In fact, the 
oral method now so commonly in use for the instruction of deaf-mutes 
must be practised in all cases of defective speech. 

The education of deaf-mutes has received much attention of recent years, 
more especially in Germany, and schools are now established throughout the 
country where the education of deaf-mutes is carried on on the oral system. 
By this system the senses of sight and touch are made as far as possible to 
take the place of the defective sense of hearing. 

If the patient has become deaf after it has learnt to speak, everything 
must be done to assist it to retain the faculty of speech and to discourage the 
use of sign-language. The child must be encouraged to speak, the words 
that are wrongly pronounced being corrected as far as possible by showing 
the child the exact position of the mouth, lips, tongue, or larynx, and by 
making it repeat the word until it has pronounced it correctly. New words 
are taught in a similar manner, and by showing the child the objects, or 
pictures of the objects, taught. 

The instruction of congenital deaf-mutes is most usefully commenced at 
six years of age ; before this time it is difficult to fix the child's attention for 
sufficiently long together ; indeed, many children do not manage to learn 
much till they are seven years of age. It need not be said that the training 
of deaf-mutes in the use of oral language is a tedious and difficult process, 
requiring a special training and much patience on the part of the teacher. 
The deaf-mute has not only to learn to speak, but also to understand what 
is said to him by watching the movements of the speaker's lips. After many 
years of training the clever deaf-mutes are able to leave school and converse 
with others sufficiently to enable them to learn a trade and earn their own 
living. 1 

Mental Affections in Childhood 

All degrees of intellectual feebleness are met with during infancy and 
childhood, ranging from complete amentia, the result of an ill-developed or 
damaged brain, to mere backwardness or dullness of the mental powers. 
The classification of such is roughly made when we speak of idiots, imbeciles. 
and backward children, though in using these terms it must be borne in 
mind that no sharp line can be drawn between idiots and imbeciles, and, 
moreover, there are objections to both terms, inasmuch as the one is a term 
of reproach and the other is frequently applied to those who are the subjects 
of senile dementia. Dr. Langdon Down has proposed a classification based 

1 For details of the methods o\ oral instruction, see A.;/- b\ Hartnunn 

(Cassell's translation). 



520 Diseases of the Nervous System 

upon etiology, having the merit of simplicity, and which is often of practical 
value with regard to treatment and prognosis. His classification is as 
follows : 

1. Congenital idiocy. 4. Cretinism. 

2. Developmental idiocy. 5. Backward children. 

3. Accidental or acquired idiocy. 6. Syphilitic idiocy. 

1. The congenital group includes by far the largest class, those in whom 
some mal-development of brain or some brain-damage takes place early in 
intra-uterine life, and who in consequence are never in possession of an 
average amount of brain power. The members of this group usually show 
within a few months of birth that they are not like ordinary children. The 
mother notices that the infant when a month or two old does not take 
notice as it should do ; it pays no attention to a bright light or sound, it does not 
recognise its friends by a smile, or appear to hear its nurse's voice. As time 
goes on it makes no attempt to sit up or hold toys in its hands, its muscular 
system is weak, and its face wears a vacant expression. At a year or 
eighteen months old it has made no progress in walking or in using its 
limbs, or perhaps it cannot utter any articulate sound ; it slavers continually, 
the saliva running from its mouth on to its frock, and it has no control over 
its urine and faeces. As its muscular power gradually increases, it learns 
to walk, perhaps to say a few words, and, if carefully looked after, to become 
more cleanly in its habits. At three or four years of age it cannot understand 
anything that is said to it, it takes no notice of anything in its daily walk, 
and can only utter one or two articulate sounds. Often they are uncertain in 
their temper and mischievous. . 

The physical characters as well as the degree of intelligence possessed 
by congenital idiots are very various. They mostly have coarse, harsh skins, 
slow circulations, and suffer from constipation. They are exceedingly apt 
to suffer from various tubercular manifestations. They nearly always remain 
stunted in growth. Congenital idiocy may be associated with a peculiar 
formation of the skull, corresponding roughly to the configuration of the 
brain inside ; while some crania are small, it must not be supposed that small 
heads are constantly present in congenital idiots : in some cases the head 
is symmetrical and well shaped, and of average size. Congenital idiots may 
have microcephalic (Aztec type) or small heads, macrocephalic or large 
heads, dolichocephalic or long heads, brachycephalic or broad heads (Mon- 
golian type). Sometimes there is a want of symmetry on the two sides of 
the cranium, or there is a deficient development of the frontal or occipital 
region. Various conditions of the mouth found in congenital idiots have 
been especially emphasised by Langdon Down ; these, it is needless to say, 
are not universally present. The palate is inordinately high and arched, and 
often unsymmetrical ; the tongue is usually large, and its movements are apt 
to be badly co-ordinated and awkward ; the fungiform papillae are hyper- 
trophied ; the mucous membrane of the pharynx is apt to be thickened and 
congested, the tonsils hypertrophied, and post-nasal adenoids may be present 
Slavering due to paresis of the muscles of the lips and tongue, as well as 
to the hypertrophy of the glands of the mouth, is very common. Dr., 
Langdon Down looks upon slavering as of some diagnostic importance 



Mental Affections in Childhood 521 

being nearly always connected with mental feebleness. The teeth are late 
in appearing and quickly become carious. 

2. Developmental. — In this group are included those who show no 
marked signs of being wanting in intelligence during infancy, but who during 
childhood or youth may show signs, often suddenly, of a mental breakdown 
and arrest of the development of the mental powers. This change may come 
at any time during childhood, but more especially on the approach of puberty. 
This sudden change often comes as a great surprise to the friends ; the 
child's head is well-formed, he looks intelligent, quite unlike the appearance 
of an idiot, and they are at a loss to account for the change, or attribute it 
to some trifling disorder. Sometimes the first intimation of the crisis is that 
the child ceases to talk : such was the case in a little boy seen by us, who 
was perfectly intelligent and bright up to /\\ years, when he suddenly ceased 
to speak and gave over playing with toys, his principal employment being 
to throw his toys on the floor and proceed to kick them about the room ; he 
hardly seemed to know his mother, though at other times he appeared to 
understand. He eventually recovered. 

In other cases the change comes at the second dentition or at puberty : 
such children are apt to be morbidly conscientious, believe they have told 
lies or stolen, or, on the other hand, they become wayward, mischievous, 
unkind to their brothers and sisters, and disobedient. (See Hysteria.) 

Epileptic fits are apt to appear at this period. Dr. Langdon Down has 
noticed that these cases often have a scaphocephalic head, which is ' prow- 
shaped ' anteriorly, the prow corresponding with the inter-frontal suture,, 
which forms a prominent ridge. Such cases, according to this author, are 
apt to break down by over-pressure at school or from over- excitement during 
childhood. 

3. Accidental or Acquired. — To this class belong those who do not 
inherit any insane tendency, and who would become healthy, intelligent 
children but for some accident which damages the brain at birth, or some 
lesion at a later period. Reference has been already made to cases of post- 
partum paralysis (see p. 471) due lo meningeal haemorrhage occurring during 
birth ; such are often not only paralysed, but mentally feeble. There is strong- 
reason to believe, as already stated, that damage done to the convolutions 
on the surface of the brain by a meningeal haemorrhage when an infant is 
in a condition of asphyxia is the cause of the feebleness of intellect, and 
possibly such cases may escape paralysis, the motor centres escaping damage. 
In another class of case the infant is quite well, and its development is satis- 
factory, till it has some acute illness with cerebral symptoms, mostly during 
its second year. This may be followed by hemiplegia, or there may be no 
paralysis, but the mental development is interfered with. Such children 
often suffer from convulsions and finally become epileptics. 

4. Cretinoid Idiocy. Sporadic Cretinism. Congenital iviyxoedema. 
Cretinism is endemic in mountainous districts of Europe, especially in the 
Swiss Alps ; it is comparatively rare in this country, though examples may 
be met with in the hilly parts of Derbyshire, Yorkshire, and Somersetshire. 
Examples of this form of cretinism may be met with in asylums. Dr. 
Shuttleworth records a remarkable case, who died at the age oi twenty J 

in the Royal Albert Asylum at Lancaster. In such cases there is usually. 



522 



Diseases of the Nervous System 



l3ut not universally, an enlarged thyroid gland, and goitre usually prevails 
in the same localities. 

The form of cretinism of most interest is the form which was described 
by Hilton Fagge under the name of 'sporadic cretinism.' It is, however, 
by no means unlikely that these cases are in reality more related to myx- 
cedema than to the form of cretinism so well known in the mountainous 
■districts of Europe. They differ from the latter in that the thyroid is absent, 
and the skin and subcutaneous tissues are thick and myxedematous. Ex- 
amples of this form have been met 
with in all parts of the country, 
and they do not seem to be more 
common in hilly districts than in 
large cities or in level country dis- 
tricts. 

In many of the cases which 
have come under observation there 
has been a history of the child 
being born of healthy parents, and 
of being well till some illness oc- 
curred such as measles or typhoid 
fever, after which the child ceased 
to grow and gradually developed 
the peculiar physiognomy of cre- 
tinism. In one of our own cases 
the boy was said to have been well 
till an attack of enteric fever at 
seven years of age ; in a case 
recorded by Fletcher Beach the 
disease dated from whooping cough 
at twenty months. In other cases 
the history points to the child 
having been affected from birth. 
There is reason also to believe that 
cretinoid changes are in operation 
during pregnancy, and that some 
of the cases in which softening of 
the bones is supposed to be due to 
infantile osteo-malacia are in reality 
fcetal cretinism. 

The physiognomy of cretins is very peculiar and characteristic. They 
are dwarfs, being markedly stunted in growth : in one of our own cases, that 
of a boy aged 12 years, he measured 34 inches high and weighed 28 pounds. 
In two cases of Hilton Fagge's, one, aged i6| years, was only 32 inches high ; 
another, 20 years old, was only 28 inches in height. 

Their heads are large and broad, often flattened at the vertex ; the face 
is broad, the eyes wide apart, the nose flattened, and the lips are large and 
pouting. The tongue is strikingly large and thick, and sometimes hangs 
from the mouth ; the belly is tumid, the lower limbs are disproportionately 
short as compared with the body, the gait is awkward and waddling. The 




Fig. 



-Cretin. Walter P., aged 5 years, height 
31 inches, weight 28 lbs. 



Cretinoid Idiocy 



523 



skin is coarse and thick, and of a sallow colour ; in some the subcutaneous 
tissues are thick and myxcedematous, Usually no thyroid is present, or, if 
present, is very small, but in almost all cases described peculiar fatty tumours 
are present in the posterior triangles of the neck behind the sterno-mastoid 
muscles and immediately above the clavicles. These tumours are soft, 
movable, and lobulated ; they send processes behind the sterno-mastoid 
muscles and also beneath the clavicles. 

The degree of intelligence in these cases differs : mostly they are childish 
in their ways rather than imbecile. In one of our cases the boy was em- 
ployed by his father, who was 
a butcher, to stand outside 
the shop on Saturday nights 
and shout out the price of 
meat. His peculiar appear- 
ance and quaint remarks 
always attracted customers. 
Cretins are apt to suffer from 
tuberculosis both of the bones 



Fig. 103 represents a boy of 
five years, the subject of cretinism. 
He was never right from his 
birth ; his brothers and sisters 
were healthy. He has never 
talked, only utters grunting 
sounds. Hardly understands any- 
thing said to him, but laughs if 
amused. The skin is coarse and 
the subcutaneous tissues thick. 
He has large lips and tongue ; his 
hands and feet are disproportion- 
ately large. No thyroid gland 
■can be felt ; the supraclavicular 
pads are present. He has caries 
-of the ethmoid bone and a chronic 
discharge of pus from the left eye. 
Fig. 104 illustrates a similar case, 
four years of age ; she could not 
stand without help. 

All degrees of severity Fig. 104. -Cretin. 

may be met with in congeni- 
tal myxcedema, and the slighter cases are very apt to be overlooked. In a 
case coming under our notice a child born deaf showed signs o\~ myxcedema, 
and greatly improved on taking thyroid extract. A sister and brother were 
also deaf (congenital), and curiously enough the sister has a much enlarged 
(cystic) thyroid gland. 

5. Backward Children. — The name sufficiently indicates this class of 
case. It is often difficult to say whether a child is only behindhand in 
development or his mental powers are deficient In most cases time will 
decide this. Backwardness is at times associated with epileptiform tits, or 
other nervous troubles. Children of this class are a constant source of 




524 Diseases of the Nervous System 

anxiety to their parents ; they go to school and always gravitate to the 
bottom of their class, being perhaps left behind by their younger brothers 
or children many years younger than themselves ; out of school they are 
bullied or teased by their playmates. It is often difficult to know what to 
do with them ; certainly neither a large school nor home life is suitable. 
They are best educated in a small school where backward boys are received 
and special attention paid to them. 

6. Idiocy due to Congenital Syphilis, — The statistics of asylums 
for idiots and imbeciles do not support the view that mental feebleness in 
children is due to any large extent to the results of inherited syphilis. Dr. 
G. E. Shuttle worth 1 records that out of 1,000 inmates at the Royal Albert 
Asylum for Idiots at Lancaster, in only ten cases was there any reason for 
suspecting syphilis, and in four only the evidence was satisfactory. We 
have already referred (pp. 458 and 484) to certain lesions, such as meningo- 
encephalitis and endarteritis, which give rise to brain softening and complete 
dementia ; but such cases are rare, and are usually fatal at a comparatively 
early period of life. The commoner form of syphilitic idiocy does not 
manifest itself till the child is some six or seven years old, or even later, and 
takes the form of a sort of dementia or nervous break-down. The child 
has perhaps learnt to read and shown a fair amount of intelligence ; it then 
gradually becomes more and more stupid and dull, and finally becomes 
completely demented. In some cases there is some form of paralysis and a 
tendency to epileptic seizures. In all such cases it is important to inquire 
for a history of syphilis, and to carefully examine the patient for evidence of 
this. Keratitis, scarring about the mouth, pegged teeth, disseminated 
choroiditis &c. should be looked for. 

The changes found in the brain in these cases consist in a chronic end- 
arteritis and meningitis, there is also thickening of the skull. 

Morbid Anatomy. — Space will not allow of any description of the malfor- 
mations or lesions found in the brains of idiots or imbeciles. The varieties 
of malformation found are very numerous ; the brain may be abnormally 
small, the frontal or posterior lobes may be ill-developed, the two halves 
may not correspond, or the corpus callosum or commissures may be absent. 
In another class of case there may be chronic meningitis, pachymeningitiSj 
or atrophy of the cortical centres. 

Treat?ne?it. — The physical and intellectual training of children of deficient 
mental power is best undertaken in some institution specially equipped for 
the purpose. Home is certainly not the best place for their education. In 
the large majority of instances they are either over-indulged or neglected by 
their parents, brothers, and sisters. The association of the cleverer brothers 
and sisters often produces a feeling of discouragement in the feeble-minded,, 
and of hopelessness at the wide gap which separates them from others. The 
discipline of a well-managed school or institution is of the greatest advantage 
in teaching them self-control and self-respect, and the companionship of 
those who are more or less on an equality as far as intelligence is concerned 
is calculated to bring out their mental powers far more than is the association 

1 ' The Influence of Hereditary Syphilis in the Production of Idiocy or Dementia,' by 
J. S. Bury, M.D. — Brain, Part XXI. ' Idiocy and Imbecility due to Inherited Syphilis," 
by G. E. Shuttleworth, B.A. , M.D. — American Journal of Insanity , January 1888. 



Treatment of Mental Defects 525 

with those that are greatly their superiors. If a school education is necessary 
for the children of parents who are in comfortable circumstances, how much 
more is the shelter of an institution necessary for the feeble-minded among 
the lower classes ! The Board school refuses to be troubled with them ; they 
are teased and worried by their companions in the streets, while they are 
alternately over-indulged or scolded and neglected by their parents ; their 
life is miserable, and they grow up useless members of society and an 
encumbrance to their friends. Unfortunately the several excellent public 
institutions for the training and education of feeble-minded children in this 
country are too few in number for the work they have to do. Moreover, they 
labour under an unfortunate name, viz. ' Asylums for Idiots and Imbeciles, 
when as a matter of fact they are not asylums for providing a home for 
useless members of society, but schools where weak-minded children are 
trained to take their part in the battle of life. These circumstances un- 
doubtedly operate in the minds of parents, who might otherwise be not averse 
to sending their children to training schools, but who shrink from branding 
them as idiots or imbeciles. 

As an example of what a training school can be, the ' Albert Asylum ' at 
Lancaster may be taken as a model. Children are received of all degrees 
of mental deficiency, from the most feeble-minded idiot to the merely back- 
ward child ; the children of the poorest, who can contribute nothing towards 
their maintenance, are admitted; while there is an attached private house for 
the reception of the children of the wealthy, replete with all the luxuries of 
home life. 

It is needless to say that children who are idiots or weak-minded need a 
plentiful supply of good food ; that especial care must be taken to keep their 
apartments warm as well as ventilated, as they are exceedingly prone to suffer 
from pneumonia and tuberculosis. 

No provision is made in this country for the education of the dull or 
backward children of the lower middle or working classes. For children of 
ordinary intelligence the Board schools of our large towns provide an 
excellent education, but no special classes are formed for those of dull 
comprehension ; they are refused admission to the ordinary classes, and 
frequently mope their time away at home, with no education at all. There 
can be little doubt that in all large towns in this country, as in Norway and 
Sweden, small classes should be provided for the dull and backward scholars, 
so as to obviate the necessity of refusing them an education, as is done at 
present. In the worst cases of this class, where there is real mental deficiency, 
education away from home is unquestionably the best. 

Craniectomy. — Recently an operation under this name has been intro- 
duced, based on the fact that in certain cases of mental deficiency the defect 
is due to premature closure of the cranial sutures and consequent arrest of 
growth of the brain. The operation consists in the removal of a strip of 
bone along one or both sides of the middle line of the skull, or in some cases 
over the motor area, thus allowing the brain room to grow. The operation 
is a somewhat serious one, but has been followed by at any rate temporary 
improvement in some cases. We have tried it in two cases of hopeless de- 
ficiency, the result of infantile meningeal haemorrhage, but in such conditions, 
as might have been expected, no marked improvement followed. It is clear 



526 Diseases of the Nervous System 

that a good result can only be looked for when the brain is small and un- 
developed, but not actually anywhere destroyed. Both our cases recovered, 
but in one there was for a time marked hyperpyrexia, apparently a direct result 
of the operation from disturbance of the brain, and not due to septic causes ; 
one of Mr. Horsley's cases died of a similar condition. The brain from one 
of our cases, which died some months after the operation from causes uncon- 
nected with it, is figured at page 479 (fig. 97). 

Cases suitable for the operation are those in which there is mental de- 
ficiency with microcephalus and closure of the sutures, but no evidence of 
destruction of brain by haemorrhage or other injury. 

The treatment of cases of congenital myxcedema with thyroid extract 
forms one of the most striking therapeutical advances of modern times. 
The effect in most cases is striking ; under the influence exerted by a few 
grains of thyroid extract daily the child begins to grow, his intelligence is 
improved, and he gradually loses the peculiar idiotic look, so that in six or 
even three months the change is in some cases simply marvellous. It is 
well to begin the thyroid treatment by giving small doses, watching the 
effect carefully, and increasing as may be necessary, a dose equivalent to 
T ^ to i of a fresh sheep's thyroid may be given daily. If the child becomes 
sick or feverish it must be omitted for a while, and the same dose may be 
given every other day. Rapid loss of flesh, weakness, slow pulse, should be 
taken as signs to reduce the dose. The treatment must be continued for 
months, and perhaps years, intermittently. In all backward, stunted 
children with rough skins and constipated bowels we should try the thyroid 
treatment. 



52; 



CHAPTER XXIII 

DISEASES OF THE NERVOUS SYSTEM — continued 

Spina Bifida 

Spina BIFIDA is a congenital malformation in which there is non-union of 
the laminae of one or more vertebrae, together with a protrusion of a sac 
composed of the spinal cord or its membranes through this opening. The 
deformity may be considered as due to a failure of the mesoblast to interpose 
itself between the spinal and cutaneous epiblast, with or without lack of coales- 
cence of the medullary folds themselves. The protrusion may occur at any part 
of the spine, and may extend throughout nearly its whole length ; usually 
only three or four vertebrae are involved, and the lumbar or sacral region is 
the part most commonly affected. 1 Very rarely the bodies of the vertebrae 
are divided, and the hernia projects forwards or laterally. In some instances 
there is no protrusion, though the laminae have not united ('spina bifida 
occulta '), and occasionally there is more than one hernia. 
Three kinds of spina bifida are recognised : 

1. Protrusion of the spinal membranes only : ' spinal meningocele.' 

2. Protrusion of the membranes together with the spinal cord and nerves : 
* meningo-myelocele.' 

3. Protrusion of the membranes and cord, the central canal of the latter 
being dilated to form the sac : ' syringo-myelocele.' 

To these should be added the cases where the medullary plates fail to 
coalesce — ' myelocele' — and the central canal opens upon the surface, a con- 
dition incompatible with life for more than a few days. Also a meningo- 
cele may coexist with a 'syringo-myelocele,' constituting a ' syringo-meningo- 
cele ; ' and finally there is ' spina bifida occulta.' - 

The second kind of deformity is much the most common, forming 63 per 
cent, of all the cases 

In the first form the swelling is usually small, and may protrude merely 
between two almost normal spines ; the cavity of the sac is the subarachnoid 
space, the swelling is often covered with well-formed skin, and paralytic com- 
plications arc often absent. 

The vertebral laminae vary much in development : the gap maybevery 
wide and the laminae much stunted, or they may form prominent everted 
borders to the orifice. 

1 Eighty-nine'eases out of 125 collected by the Clinical Society were Lumbar or sacral. 
- Vide Bland Sutton, Lancet, February 25, [888, 



528 Diseases of the Nervous System 

The central canal of the cord is often dilated in the first two forms as 
well as in the third, and the position of the cord in the sac varies ; it maybe 
slung up in the sac by a sort of mesentery, but in any case is very imper- 
fectly developed, and is occasionally transfixed by a bony process crossing 
the canal. 

Syringo-myelocele is very rare ; the sac is composed of spinal membranes 
j)lus the cord, and, the cavity being the dilated central canal, the nerves are 
embedded in the sac wall and do not cross the cavity. 1 

The fluid in a spina bifida consists of 98*9 per cent, of water with soluble 
salts and a trace of sugar, or at least some copper-reducing substance ; also 
small quantities of globulin ; it is, in fact, cerebro-spinal fluid. Where, how- 
ever, the cavity of the sac is continuous with the subdural space, no sugar 
will be found. 2 

In meningo-myelocele, the common form, the sac is formed of dura 
mater lined by arachnoid (both 'layers'), hence the cavity is the subarach- 
noid space. The spinal cord traverses the sac and blends with its roof; from 
the flattened thinned-out cord the spinal nerves arise and pass across the 
sac to their respective foramina. The surface of the sac may be covered 
entirely with skin, or may be thin and transparent, only consisting at its 
upper part of the membranes, or membranes covered with an imperfect 
epidermic layer, while at the sides the skin is usually better formed. Some- 
times a dimple or longitudinal furrow in the middle line marks the attach- 
ment of the cord and shows its presence in the sac, an important point in 
the question of treatment. Sometimes the sac is loculated. 

The tumour resulting from spina bifida is median in position, usually 
sessile, fluctuant, translucent in varying degree, according to the amount of 
healthy skin covering it. Lateral meningocele has been, however, met 
with. The contents can be partially reduced into the spinal canal, 
unless the communication has been shut off (false spina bifida). The 
surface is not uncommonly ulcerated, and is sometimes marked by 
nsevoid tissue as in the case of meningoceles. The swelling becomes tense 
on the child crying, and there is often some associated deformity ; hydro- 
cephalus, meningocele, talipes, harelip, a peculiar webbed condition of the 
thighs ('siren'), or other deformity may coexist, and the subjects of spina 
bifida are often marasmic and soon die ; in other cases, however, they are 
fat and hearty. We have seen them too fat, the subject of a sort of diffuse 
lipomatous condition such as is sometimes seen in cases of talipes. On the 
whole, paraplegia, talipes, and hydrocephalus are the three commonest com- 
plications. ' Trophic ' ulcers are sometimes seen on the feet. 

Diagnosis. — The diagnosis of spina bifida can only be doubtful where 
there is a complete skin-covering to the tumour. In such cases congenital, 
sacral, or other tumours — hygroma, teratoma, or lipoma — may be mistaken 
for spina bifida, and the possibility of the communication with the spinal cord 
having been shut off must also be borne in mind. The presence of solid 
masses in a median tumour and the absence of general fluctuation would 

1 A case of this sort has besn recorded by Morton in the Brlstjl Med. Chir. Jour. 
March 1892. 

2 A case of this nature was reported by Pearce Gou'd in the Clit. Soc. Trans. 1882. 
Injection cured the patient. 



Spina Bifida 529 

point to a teratoma or lipoma, while a hygroma is more spongy, usually 
flatter, and often not exactly median. The presence of naevus-stains may 
raise the question of whether the whole swelling is not nasvoid. The fixity 
.of the tumour to the spine, its reducibility, the possibility of feeling the edges 
of the opening in the laminae, and the coexistence of other deformities may 
throw light upon a doubtful case. In some instances puncture with a fine 
needle and examination of the fluid drawn off may be required ; a highly 
.albuminous fluid would be inconsistent with spina bifida. Non-congenital 
tumours cannot, of course, be confounded with spina bifida. The per- 
sistence of communication with the meningeal cavities can be determined 
by variations in size of the swelling. The term 'false spina bifida,' usually 
limited to cases where the sac no longer communicates with the sub- 
arachnoid space, is sometimes applied to any median congenital tumour 
.along the spine. 

Prog?iosis. — Nearly all cases of spina bifida left to themselves die, 
mostly from meningitis after rupture of the sac, or from marasmus ; some, 
however, recover completely, the sac shrinking up and forming a mere 
puckered cicatrix. Occasionally spontaneous cure takes place in utero, 
and even rupture is not universally fatal. Cure of the spina bifida, it must 
be remembered, does not imply cure of paralysis or other complications. 

Treatment. — Though simple repeated tappings, pressure, ligature, and 
excision have all occasionally proved successful in the treatment of spina 
bifida, the Clinical Society's report shows that the safest and most gene- 
rally applicable plan is that of injection, and probably Morton's fluid l is 
the best for this purpose. Either ligature or excision is almost necessarily 
fatal where the case is one of meningo-myelocele, and, as this is the most 
■common form,' 2 and it is impossible to be sure in any given case that a 
simple meningocele is present, the plan is only occasionally applicable. 3 

Treatment by injection is managed as follows : The child should be 
held back downwards, and a fairly fine injecting syringe should be charged 
with Morton's fluid ; the needle is then passed in obliquely through the skin 
and from fifteen minims to a drachm of the fluid injected. Care must be taken 
that the puncture is made through skin and not through thin membrane, 
and that it is well away from the middle line, both to diminish the risk of 
subsequent leakage and to avoid injury to the cord or nerves. After the 
injection, the child must be kept upon its back, the puncture sealed with 
collodion, the tumour packed well round with absorbent wool, and a flannel 
bandage applied. It is perhaps better to withdraw some fluid before injecting. 
and the child must be kept entirely in the supine position, to prevent the 
fluid from passing into the spinal canal. If the tumour docs not shrink and 
no ill effects follow, the injection should be repeated at intervals oi a fort- 
night. Occasionally the tumour does not begin to shrink for a month or two 
after an injection, as in a case related to us by Dr. Wallace, of Longsight 

1 Iodine gr. x, iodide of potassium gr. \\x, glycerine .~ ; i. The amount of iodine may 
be increased up to gr. \.\\. 

- Prescott Hewett found only one case out of twenty in which there was no nerve 
element in the sac. 

5 Mr. Mayo Robs, mi, of Leeds, and others, have had some successful cases, bul I 
remain as above stated. 

M M 



530 



Diseases of the Nervous System 



Injection may fail to produce any effect, may result in immediate death, 
may be followed by leakage or by hydrocephalus ; a single injection may 
cure, or several may be required. This plan should be employed in all 
cases unless the child is obviously marasmic or dying from rupture of the 
sac, or unless the tumour is quiescent and giving rise to no trouble ; or, of 
course, if it is shrinking spontaneously, no treatment should be adopted. 

Sometimes a spina bifida is ruptured at birth, or sloughs shortly after- 
wards from pressure ; nothing can be done for such a case except to dust it 
over with iodoform and protect it carefully from pressure and contamination 
with the child's discharges. We have not seen a case recover when the sac 

has been ruptured in this way, though 
agsJ recovery does occasionally occur 

(Maylard). Superficial ulceration is 
less serious and should be managed 
in the same way. Even if the spina 
bifida is cured by injection, it is not 





Fig. 105.— A case of cured Spina Bifida (by 
injection), with co-existing Talipes. 



Fig. io5. — Shows a section through a Spina- 
Bifida cured by injection. A small cavity 
still remains. The child died some time after 
of scarlet fever. 

rare for hydrocephalus to appear 
later ; hence the mortality, direct or 
indirect, among these cases is very 
high. 

As already mentioned, in certain 
cases the sac becomes shut off from 
the general cavity of the membranes and the cyst remains without com- 
munication with any important structures : such result can only occur in 
meningoceles ; the tumour then usually requires no treatment ; it may, how- 
ever, be tapped or injected and excised^with probable impunity. These cases 
and sacral spina bifida are the ones most likely to be successfully treated by 
excision. 

In connection with spina bifida must be mentioned the so-called sacral 
or coccygeal dimple described by Lawson Tait and others. This is a 
small dimple or depression in the skin over theUower part of the sacrum or 
upper part of the coccyx ; it can often be obliterated by traction upon the 
skin. It probably results from imperfect obliteration of the dorsal furrow, 



Spina Bifida 



531 



a sort of incomplete spina bifida. Fig. 107 shows a more marked condition 
of the same thing, which was associated with talipes. It has been pointed 
out by Dr. Dunlop, of Jersey, 1 that the dimple may be associated with bending 
back of the coccyx. Another view of the ori- 
gin of this little depression, which is quite com- 
monly to be found, is that it represents the ' pos- 
terior umbilicus,' or 'blastopore.' It has been 
supposed to be the remains of the neurenteric 
canal. Congenital sacral fistulae are a more 
marked condition of the same thing : they may 
cause trouble by retention of sebaceous secretion 
and require removal ; a tuft of hair or ' caudal 
appendage ' has been found in the neighbour- 
hood of these fistulae (Terrillon, Gueniot, &c). 
The case here figured (fig. 107) appears to be an 
intermediate condition between the ordinary 
spina bifida and the rare condition described as 
' spina bifida occulta,' in which the laminae of 
one or more vertebrae are deficient, but there is 
no hernial protrusion. In 'spina bifida occulta' 
the site of the deficiency is marked by a local 
overgrowth of hair, and there appears to be 
usually a coexisting (resulting) tendency to the 
development of perforating ulcer of the foot and 
pes varus. We have noticed an overgrowth of 
hair and a formation of trophic ulcers in cases 
of spina bifida cured by injection ; both the 
hypertrichosis and the ulcer developed only 
when the tumour was more or less completely 
shrunken. In such cases endarteritis and neu- 
ritis of the affected foot have been found, with 
great hypertrophy of the muscular coat of the 
arteries. In cases of spina bifida both manifest and 'occult,' paralyses and 
contractures of the lower extremities have been relieved by operation, and 
the removal of bands and fibrous or fatty masses pressing on the cord or 




Fig 107.— Slight sacral Spina Bifida 
which has undergone spontaneous 
cure. The girl had also Talipes, 
and was mentally dull. There was 
an ulcer on the dorsum of the foot. 



Meningocele 

Malformations corresponding to spina bifida are not rarely met with in the 
head. The most common form is a hernia of the meninges forming a 
meningocele, the cavity of which is the subarachnoid space. In other' in- 
stances the protrusion contains brain substance as well— encephalocele, or 
hydrcncephalocele, or mcningo-encephalocele ; the last is, according to 
Treves, the commonest, and pure meningocele the rarest form. 

These herniae arc most common in the occipital region, the protrusion 
taking place through a median opening corresponding to the space between 
the centres of ossification of the supra-occipital bone. In other instances it 
occurs at the root of the nose, through the suture between the frontal and nasal 

1 Lancet, May 61 t88a, 



532 



Diseases of the Nervous System 



bones, or at one or other angle of the orbit, or at other parts, 1 the pharynx 
&c. The general characters of these cysts need no further description 
here ; they are precisely those of a spina bifida, except that the skin over a 
meningocele is more often normal. The fluid is often partially or wholly 
reducible, and its reduction may give rise to pressure symptoms ; the swell- 
ing becomes more tense when the child cries, and is more or less trans- 
lucent according to its contents, whether fluid or cerebral. The course of 
these cases is often the same as that of a spina bifida : the swelling grows 
and ruptures, and the child dies ; sometimes, however, it shrinks after or 
without rupturing. 

Diagnosis. — The diagnosis is in most cases easy : the swelling is in the 
position of a weak spot in the skull ; it is congenital. The opening in the 
skull can usually be felt, and the other characters mentioned suffice to dis- 
tinguish it. Sometimes, however, especially when small, it is difficult or im- 
possible to distinguish meningoceles from dermoid cysts, or cysts connected 
with naevij especially as naevoid patches are common on the surface of 
meningoceles. Dermoid cysts sometimes cause perforation of the skull 





Fig. 108. — Occipital Meningocele. 



Fig.* 109. — Frontal Meningocele. Spontaneous cure, with 
resulting deformity of the nose. (Dr. Moritz's case.) 



beneath them, and hence are very difficult in such cases to diagnose with 
certainty ; they are, however, usually more mobile and less affected by pres- 
sure than meningoceles. The deformity is often accompanied by idiocy, 
paralysis, or spastic contractures, and other malformations. In some cases 
the protrusion may attain enormous bulk, the greater part of the cranial con- 
tents being lodged outside the skull. Most museums contain specimens of 
this sort, which have, however, no practical surgical bearing. 

Treatment. — Unless the tumour is enlarged, no treatment except pro- 
tection is wise ; should anything be desirable, repeated tappings or injection, 
as in the case of spina bifida, is the best course for meningoceles. Attempts 
have been made to excise the tumours, with sufficient success to encourage 
further trials, in selected cases. We have successfully excised an occipital 
meningocele in which the tumour did not communicate with the membranes ; 
but in the operation the membranes, or at least another sac, were opened. 

1 The late Dr. Carrington has recorded a case of interparietal hydrencephalocele {Clin. 
Soc. Trans. 1881) ; and the protrusion sometimes takes place through the foramen mag- 
num Holmes, St. George's Hospital Reports, 1866) : in this case the cyst was loculated. 



Meningocele 533 

No ill result followed. If excision is attempted the skin should be as far as 
possible dissected back from the membranes, and the latter either tucked 
into the skull or removed and their edges stitched together. We have also 
excised an occipital meningo-encephalocele in which a piece of the 
cerebellum of the size of a walnut was removed ; the child recovered, though 
it developed hydrocephalus after the operation. 1 

Schatz reports favourably of the treatment of occipital meningoceles by 
puncture and pressure, and records a cure in three cases by constriction of 
the pedicle with clamps. {Berlin. Klin. Woch. 1885, No. 28, p. 371.) 

Much, deformity is sometimes produced by the presence and shrinkage of 
a meningocele (fig. 109, kindly given us by our friend Dr. Moritz). 

Occasionally meningoceles protrude through the roof of the pharynx or 
nasal cavities : in such cases mistakes as to the nature of the swelling have 
led to speedily fatal results after operation. 2 

Spinal Meningitis 

Spinal meningitis mostly occurs in its acute form in association with 
cerebral meningitis, and in its chronic form in connection with spinal caries 
Acute cerebro-spinal meningitis has already been referred to (p. 447), and 
the symptoms of spinal meningitis, when superadded to those of cerebral 
meningitis, discussed. The dissociation of the symptoms of each is not 
easy, as cerebral disease gives rise to symptoms closely resembling those 
given by a spinal lesion. Thus, basal meningitis, especially when it occurs 
low down around the pons, medulla, and cerebellum, will produce tetanoid 
rigidity with spasms of the muscles of the back and neck. A tumour of the 
middle lobe of the cerebellum may produce acute pain referred to the spine 
and spasm of the erector spinas (see case, p. 465). On the other hand, 
spinal meningitis, either tubercular, simple, or purulent, may be found post 
mortem, having given no definite symptoms during life, certainly not those 
usually associated with spinal meningitis. 

The most characteristic symptoms of spinal meningitis are shooting 
pains down the limbs and round the body, with hyperesthesia of the skin, 
rigors, quickened pulse, and fever. There are rigidity about the limbs, 
retraction of the head, and tenderness about the spine. The diagnosis is 
often difficult : hysteria, tetany, and the cramps associated with acute 
intestinal catarrh, as well as cerebral meningitis, may be mistaken for it. 
Synovitis of the vertebral joints may resemble meningitis of the cord. If 
the spinal meningitis pass into the chronic stage, paresis of the upper and 
lower extremities may come on. 

Spinal meningitis is necessarily a disease which tends to a fatal termination, 
but not so certainly as cerebral meningitis : certainly, cases diagnosed as spinal 
meningitis recover. Cases such as the following are not altogether uncommon : 

A girl aged 13 years complained six days before admission of pain in the back; her 
head was drawn back, she eould not sleep for the pain. On admission she was evid< 

1 Mr. Jessop, of Leeds, also records a successful case of excision, but there was no 
distinct communication with tin- interior of the skull; hence it has little beating on the 
general question. — Brit. Med. Jour. December 30, 1882. 

- For tables as to the frequency of different varieties &c. :...■'. ["reves 
Surgery, vol. ii. 



534 Diseases of the Nervous System 

acutely ill ; she lay on her side in bed, with her legs drawn up, and there was great retrac- 
tion of the head ; there was much pain along the spine, aggravated on movement ; pain 
shooting along the arms was complained of; the pulse was 108, the temperature varied 
from 98 D to 102 Fahr. She was given chloral hydrate, and an ice-bag was applied to the 
spine; for five or six days she continued acutely ill, the temperature varying from 97 to 
102 ; there were several rigors on succeeding days : the head was retracted, any forcible 
movement forward caused pain, there was exaggerated knee-jerk, and ankle-clonus was 
present. The symptoms gradually subsided about a week after admission, leaving her 
very weak and emaciated. In six weeks she was discharged well. 

Such cases may be open to the suspicion that the inflammatory lesion 
present was in the vertebral joints or spinal muscles rather than in the 
spinal canal ; but, on the other hand, none of the other joints or muscles 
were affected, and there is no reason why a spinal meningitis should not 
occur and get well again. 

Treatment. — Rest in bed, with perfect quietness, is essential. Ice to the 
spine is probably the best local application that can be used. The pain 
must be relieved by small morphia injections, or opium may be given by the 
mouth. Instead of opium, bromides and chloral may be first tried. 

Paraplegia 

By far the commonest cause of paraplegia during childhood is compres- 
sion of the cord from caries of the bones of the vertebras. Other forms of 
paraplegia occur which may be due to myelitis, pressure on the cord 
by a tumour, following measles or other zymotic disease, an acute atrophic 
paralysis affecting both legs, and some other anomalous paralyses of un- 
certain origin. There is also the spastic paralysis of cerebral origin and 
hysterical paraplegia. 

Paraplegia from Pott's Disease. — It is important to bear in mind that 
the paraplegia which occurs in association with caries of the spine is less 
often due to direct pressure from the deformity produced by the falling together 
and bending of the vertebras than to the inflammatory products which are 
thrown out around the cord. We may therefore have a paraplegia without 
the slightest external deformity of the spine, and, moreover, a perfect recovery 
may ensue in a given case by absorption of the inflammatory products— a 
result that could hardly be expected if the compression was due to the direct 
pressure of a bent spine. The inflammatory process which commences in 
the body of a vertebra is apt to spread, so that lymph or curdy pus is effused 
outside the dura mater, between the latter and the bone, or inside the dura 
mater, and the cord is compressed, or the cord may also be affected by the 
inflammatory process. Pressure on, and inflammatory changes in the cord 
itself may take place at any part of the cord — cervical, dorsal, or lumbar 
region. Pressure is also exceedingly likely to affect some of the nerves, 
the latter being surrounded and compressed by inflammatory products as 
they pass through the dura mater and foramina. 

Symptoms. — Symptoms of compression of the cord or its branches may 
come on early or late in the disease. In the majority of cases the early symp- 
toms are those connected with deformity of the spine and perhaps irritation of 
the sensory nerves, and it is only late in the disease, when the deformity has 



Paraplegia 535 

"been well marked for many months, that symptoms of pressure on the cord 
supervene. In the minority of cases it is the weakness and paresis of legs 
with exaggerated knee-jerk that suggest the onset of spinal caries. It is im- 
portant to bear in mind that a paraplegia may exist for many months 
without any deformity of the spinal column being present, the latter eventually 
supervening, and explaining the cause of the paraplegia which had remained 
in doubt. Gowers mentions the case of a patient who had complete para- 
plegia for six months ; an experienced surgeon who examined him was un- 
able to detect the existence of spinal caries, and yet a few months later 
undoubted symptoms of bone disease set in. 

The motor paresis usually comes on gradually : the child is weak upon 
its legs, quickly tiring, and supports itself whenever possible by the help of 
chairs or tables. When the dorsal cord is compressed the reflexes are 
exaggerated ; if the sole of the foot is tickled as the child lies in bed the foot 
is sharply withdrawn ; if the knee is bent by holding the ankle in the operator's 
hand, a sharp tap on the patellar tendon gives rise to an exaggerated ' knee- 
jerk ; ' ankle-clonus can usually be readily obtained. Gradually a spastic 
paraplegia comes on : the child cannot walk, or later cannot stand, without 
help, and when lying down in bed the knees tend to draw up and the feet to 
be extended in consequence of the rigidity of the calf muscles. Usually 
there is no loss of sensation. The sphincters may be affected and bladder 
troubles may ensue if the lumbar cord becomes involved by descending in- 
flammation. Prior to the onset of motor or cord symptoms, there may be 
various shooting pains experienced along the intercostal nerves ; children 
with commencing caries of the spine will complain of ' belly-ache ' or refer 
the pain to the pit of the stomach or sternum. Thus pain referred to 
the umbilicus suggests that there is irritation of the tenth dorsal nerves 
(eighth dorsal vertebra), or pain at the ensiform cartilage to the sixth and 
seventh nerves (fourth and fifth dorsal vertebrae), or over the thorax to the 
upper dorsal nerves. There may be hyperesthesia or anaesthesia of the 
skin. 

When the cervical region of the cord suffers the symptoms are apt to be 
more marked than when the dorsal region is affected ; there may be pains 
shooting down the arms, shoulders, neck, and scalp, according to the position 
of the lesion ; hyperesthesia and later anaesthesia of the skin. The sensation 
of pins-and-needles is often complained of. There is gradual loss of power 
in one or both arms, and wasting of the muscles. The shoulder muscles, 
serratus, flexors of the elbow and supinators are affected when the fifth and 
sixth are involved ; the extensors of the wrist and fingers when the sixth and 
seventh ; and the extensors of the elbow, flexors of the wrist and ringers, 
.and pronators, when the seventh and eighth are involved. A spastic para- 
plegia may come on, as in disease of the dorsal cord. 

When the lumbar enlargement is compressed, or its branches, there is 
paraplegia, the reflexes are not exaggerated, but are abolished, and no 
knee-jerk can be obtained— that is, if the pressure is severe enough to interfere 
with the functional activity of the grey matter of this region. The sphincters, 
both of the bladder and rectum, are likely to become paralysed if a compres- 
sion myelitis of the lumbar cord takes place. 

The course of the disease varies exceedingly, and depends upon the extent 



536 Diseases of the Nervous System 

and chronicity of the inflammatory processes in the bones. Recovery from 
the paralysis may take place after the patient has been bed-ridden and help- 
less for many months and even years, and where recovery was hardly thought 
to be possible. On the other hand, the progress may be from bad to worse, 
there being a gradually extending myelitis, so that the sphincters become 
paralysed and the patient suffers from incontinence of both urine and faeces. 
Sensation may become impaired, and the patient at last dies of exhaustion or 
the results of cystitis, or not infrequently of tuberculosis or lardaceous disease.. 
For treatment see Disease of Spine. 



Myelitis 

By far the commonest inflammatory lesion of the cord in children is that 
form which is localised in the grey matter of the anterior horns, which has 
received the misleading name of ' infantile paralysis.' 

An acute transverse myelitis occurs in children as well as in adults, but 
it is apparently less common. Disseminated or focal myelitis appears some- 
times to occur during some of the zymotic diseases, as typhoid fever or 
measles. Transverse myelitis is rare before the age of ten years ; it seems 
mostly to follow exposure to cold or accidents such as occur to school- 
boys in the football field. In one of our cases, that of a boy of eight years 
of age, it followed paddling in the water. 

The symptoms are much the same as in adults ; the ultimate chance of 
recovery is, however, greater, as the cord seems to recover itself more readily 
in early life than in later years. There is usually a feeling of ' pins-and- 
needles ' in the feet, and sometimes rheumatoid pains followed by loss of mus- 
cular power. At first this may be slight, but after a few hours it becomes more- 
marked, and within twenty-four or forty-eight hours it has reached its height. 
There is loss of sensation as well as motion, varying in extent according to 
the length of cord affected. There is also incontinence of urine and 
fseces ; if the lesion is above the lumbar enlargement, the sphincters con- 
tract normally, but the control exercised by the will is cut off. The com- 
monest part of the cord to be affected is the dorsal region ; often there is 
some feverishness. 

All degrees of motor and sensory paralysis may be present. In severe 
cases almost all power is lost and the legs fall about in a helpless way, 
though usually some power of movement is retained in the toes. The 
reflexes may be completely absent. After a variable period, if the lesion is 
above the lumbar enlargement, the reflexes return and become excessive ; 
there is ankle-clonus, the knee-jerk is abnormally vigorous, and a condition 
of spastic paraplegia comes on. Sensation, if it has been absent, usually 
returns before recovery of motor power. 

The amount of recovery which takes place is variable ; we have seen 
complete recovery eventually ensue in cases where, from the amount of 
motor and sensory paralysis present in the first instance, we had not thought 
it possible. Many months in bed are necessary to effect this ; the intense 
spastic paralysis gradually lessens and may eventually disappear. 

If the lumbar enlargement is affected, not only is there complete motor 
paralysis, but the muscles waste rapidly, the rectal sphincter is completely 



Myelitis 537 

relaxed, and the urine dribbles away from paralysis of the sphincter of the 
bladder. 

If the cervical enlargement is affected, the arms are paralysed, the pupils 
may be dilated, and death is apt to ensue from interference with the nerve 
supply to the muscles of respiration. 

As an instance of a transverse myelitis occurring in the cervical region,, 
followed by partial recovery, the following case may be related : 

Transverse Myelitis.— A healthy boy when a year old was exposed to cold by lying on 
the damp grass ; he woke crying during the following night, the parents thinking he had 
pain in the stomach ; he was not convulsed ; next morning both his arms and legs were 
limp and useless, he could not move them or sit up ; there was no facial paralysis. 
Recovery gradually took place, the arms recovering completely, the legs partially. When 
seen at two years of age, the arms had completely recovered, but both legs were weak, so 
that he could not bear his weight on them, but could crawl, dragging them after him ;. 
sensation seemed impaired in the legs, there was ankle-clonus and exaggerated tendon 
reflex. The child was perfectly intelligent, and was well nourished, but the muscles of the 
leg were somewhat flabby. He has since been lost sight of. 

As instances of what were probably cases of subacute myelitis, one occur- 
ring after measles and another after what was said to be a ' cold,' we may 
mention the following cases : 

Myelitis following Measles. — Gertrude H., aged 4 years, was quite well till she con- 
tracted measles in August 1882 ; when convalescent it was noticed she could not stand by 
herself. She remained bedridden till admitted to the hospital in December. At this time 
she could not bear the weight of her body without help ; the knee-jerk was exaggerated, 
the front-tap contraction was present, there was no ankle-clonus. She slowly improved, 
and by February 1883 she could stand alone and walk with help, throwing her legs forward. 
She finally entirely recovered after some months. 

Myelitis. — George C. , aged 13 years, was quite well till May 1882, when he caught a 
cold and had a feverish sore throat ; after this his legs became weaker, though he could 
always walk with help. He was admitted September 1882 ; his legs were both weak, but 
he could walk, swaying from side to side, bending both knees very much ; no loss of sensa- 
tion, muscles react normally to both continuous and faradic currents ; knee-jerk exagge- 
rated, the slightest touch producing a jerk ; there was no evidence of any spinal disease. 
He remained much in the same condition till January 1883, when he went home. He 
finally completely recovered, after attending as an out-patient for some months. 

It is difficult to account for the symptoms in these two cases except on the 
supposition that they suffered from either compression or disseminated 
myelitis, which eventually got well. 

Dr. Thos. Barlow records a fatal case of disseminated myelitis 1 occurring" 
during an attack of measles, which proved fatal on the eleventh day of the 
disease. He quotes two cases of children, aged two years and three years 
respectively, who suffered from paralysis apparently due to myelitis when 
convalescent from measles.' 

Landry's Paralysis, or acute ascending paralysis, is said to occur 
occasionally in children ; the following case in many respects resembled this 
form as it occurs in adults : 

Edward M'L., aged n years, had good health till January 1881, when he became ill 
from the effects of cold ; in a few days he became drowsy and had twitchings in the 



1 'On a case of early disseminated myelitis occurring during measles.' — Dr, 1 hos 
Barlow, Proc. of the Royal Med.-Ckir. Soc., vol. ii. p. 146. 



538 Diseases of the Nervous System 

which were said by a doctor to be due to St. Vitus' s dance ; the movements ceased and 
left his legs paralysed ; eight days afterwards he lost the use of his arms, and he com- 
plained of pain in the head and was delirious for a week ; the weakness in the arms im- 
proved, but got worse again. When admitted in March 1881 his arms were weak, he 
moved his legs with difficulty, could just manage to raise them in bed ; no loss of sensa- 
tion ; the knee-jerk was almost absent ; no ankle-clonus. He gradually improved, so 
that by April he was able to walk without difficulty, but swayed to and fro. He finally 
completely recovered. It is possible that this case was in reality one of peripheral neuritis 
rather than any spinal lesion. 

Treatment. — Perfect rest in bed is of the greatest importance in the in- 
flammatory stage, all movements and excitation of the spinal cord being 
avoided as much as possible. The patient should lie on his side or his face 
in preference to his back, so that the spine should not be the most dependent 
part. Of local applications the spinal ice-bag is probably the best, though 
some prefer the application of moist heat with counter-irritation, such as 
mustard poultices, so as to redden the skin. Probably there are no medicines 
which can control or moderate the inflammatory lesion. Aconite, ergot, the 
bromides, have all been used with varying success. Both mercury and iodide 
of potassium have also been prescribed. 

Great care must be taken to prevent bedsores : perfect cleanliness must 
be observed, and pressure taken off any spot where the skin becomes red. 
The incontinence of urine and faeces is always a source of difficulty, as the 
urine and damp bed-linen fret the skin and give rise to sores. The best 
position for the patient is on his face, so that the urine as it dribbles away 
may be received into a bed-pan. Boracic or iodoform cotton wool may be 
used to surround the genitals and absorb the discharges. If there is retention 
of urine, the catheter must be used. No good can be expected from the 
application of the faradic or galvanic current in the early or inflammatory 
stages ; indeed, harm may not improbably be done by exciting and frighten- 
ing the child. The more at rest the cord is allowed to remain, the better 
■chance is there of absorption of the inflammatory material and recover)- of 
function of nerve elements. 

In the chronic stage good may be done by gentle friction applied to the 
muscles, and by the application of blisters or the actual cautery over the 
region corresponding to the disease. A change to the seaside, the patient 
being wheeled out in the open air in a recumbent position, is likely to expedite 
recovery by improving the general health. 

Hereditary Ataxic Paraplegia, or Friedrich's Disease, is the name 
given to a form of ataxia which commences for the most part during early 
life, and which tends to affect several members of the same family. It most 
commonly appears during the period of the second dentition or from that on 
to puberty. The most characteristic feature of the disease is a reeling gait, 
the patient swaying about both in walking and standing, a condition made 
more apparent by the closure of the eyes. As in other forms of ataxy, the 
knee-jerk is quickly lost. Failure of muscular power takes place as the 
-disease progresses. The muscles of the head and neck as well as the arms 
become affected mostly with tremor, so that when a voluntary movement is 
attempted irregular jerky movements take place. Nystagmus is a common 
symptom. The progress of the disease is very slow. The lesion in the 



Acute Atrophic Paralysis 539 

cord consists of sclerosis of the posterior and lateral columns ; the anterior 
column may also be affected. 1 

Anterior Polio-myelitis. Acute Atrophic Paralysis. 
' Infantile Paralysis ' 

Etiology. — The disease, which is usually known by the name of ' in- 
fantile paralysis,' occurs most frequently during early childhood ; but, as a 
form of paralysis exactly similar occurs during the later years of childhood 
and also during adult life, the name certainly ought to be abandoned. It 
most frequently occurs during the first three years of life, at least four-fifths 
of the cases occurring at this period (Gowers). It is less frequent during the 
first six months than it is during the last half of the first year and during 
the second. 

Very little is known as to its cause, and, while it occurs both in the strong 
and weakly, in the majority of cases in our experience it has been met with 
in typically healthy children, with a good family history, and who could not 
be said to ail anything ; and no reason could be assigned for its onset. It 
certainly appears to be commoner during the warm quarter of the year than 
at any other period. It appears occasionally to follow exposure to cold, 
such as sitting on damp grass, or it may apparently result from an injury. 
It is said to follow occasionally as a sequela of measles, scarlet fever, typhoid, 
pneumonia, acute diarrhoea. Dentition has been credited with being a 
cause, but of this there is not sufficient evidence. Perhaps the most likely 
exciting cause is over-exertion in children who have only recently learnt to 
use their legs, though this can hardly be a cause in children under a year old. 
The etiology at present remains uncertain. 

Symptoms. — The course of the disease may be conveniently divided into 
stages, and, following Gowers, they may be stated thus : 

1. An initial stage, during which the paralysis occurs, usually accom- 
panied by fever, and lasting a few hours to a week. 2. A stationary period, 
which lasts from a week to a month. 3. A period of ' regression,' during 
which the paralysis disappears in certain of the affected muscles, leaving 
■others still paralysed ; this stage usually occupies one to six months. 4. A 
chronic stage, during which atrophy occurs and deformities and contractures 
are developed. Some improvement may take place during this stage. 

1. The initial stage is usually ushered in with fever, restlessness, con- 
vulsions, muscular twitchings, and cerebral disturbance. The severity of the 
attack differs much in different cases ; it has rarely been closely observed, 
being usually attributed to dentition or gastric disorder, and only when the 
paresis has supervened has the importance of the attack been recognised. 
The pyrexia is rarely high, perhaps 101 to 102 ; there may be muscular 
twitchings of the face or the affected limb ; drowsiness, delirium, or convul- 
sions may be present. The acute attack may be entirely absent, or. what is 
more likely, ill-defined, so that it is overlooked by the friends, and the only 
history obtained is that the child was put to bed well, and that in the morn- 
ing a limb or limbs were found powerless and limp. The paralysis is usually 
first noticed after the acutencss oi~ the attack is passed, and in infants it is very 

1 See Gowers, Diseases of the Nervous System , vol. i. ; and J. S. Bury, Brain, July t8 



540 Diseases of the Nervous System 

likely to be overlooked at first, or thought to be due to weakness only. The 
paralysis reaches its height at once, or at any rate in a few days or under a 
week. It is difficult to say what proportion of cases die in this stage, for 
probably the nature of the disease would not be recognised, and the attack 
would be attributed to ' convulsions,' or the early stage of some acute disease. 
Nevertheless, such cases have been recorded, and lesions found in the grey 
matter of the spinal cord. 

There seems to be no relation between the severity of the initial attack 
and the extent of the paralysis which follows it, some of the most extensive 
and severe paralyses being accompanied by hardly any febrile disturbance. 
It is not certain whether the febrile symptoms are due to the inflamma- 
tory lesion taking place in the cord, or the lesion in the cord as well as the 
fever and convulsions are the result of some unknown process going on in 
the body. 

In some cases there is an acute attack, which passes away, leaving no 
definite paresis ; another similar attack follows, and when this clears up a 
paralysis is noted. This was the case in the following instance. A boy- 
aged two years, a patient of Dr. Sutcliffe of Stalybridge, was quite well and 
running about, when one day he was taken suddenly ill, crying, vomiting, and 
feverish ; the following evening he was convulsed ; he was put to bed and 
continued ill for two or three weeks with apparently some brain trouble ; this 
attack left him very weak ; but he gradually recovered and was able to run 
about again. He continued well for two months, when the same symptoms 
returned ; he cried with pain, there was vomiting and fever, followed with con- 
vulsions ; he remained ill for fourteen days, and just as he was being got up 
and about again it was noticed that his right leg was paralysed. When seen 
two months after, there was wasting and paresis of the right buttock, thigh, 
and dorso-extensors of the foot. 

2. After the paralysis has reached its fullest extent, a period during which 
the paresis of the muscles is stationary ensues, varying from two weeks to 
six weeks or two months. At this time the affected muscles are limp and 
powerless, so that the limb or limbs hang quite useless and flail-like. In 
the more severe cases almost all the muscles in the body appear to be in- 
volved ; the child cannot sit up, its head falls to one side through paresis of 
the muscles of the neck, its cry is weak or almost lost from weakness of 
the diaphragm and intercostals, its respiration is shallow and rapid, and its 
limbs relaxed and motionless. The paralysis may be confined to one limb 
or a group of muscles in a limb : thus an arm may hang useless by the side, 
and if raised above the head falls flail-like by the side. One or both legs 
may be powerless, and may be flexed, extended, or rotated without any 
resistance from the tonus of the muscles. Hemiplegia is rare. The reflexes 
both superficial and deep are lost, so that tickling the sole of the foot or 
percussing the patellar tendon meets with no response. It is difficult to 
judge if there is any loss of sensation or at least sensory paralysis. In the 
most severe cases we have noticed sensation is not as acute as usual : a 
spoon, which to a normal skin is unbearably hot, can be borne without eliciting 
any expression of pain on a recently paralysed foot, and in the same way a 
painfully severe application of faradaism will be borne without flinching. 
It must be borne in mind, however, that the circulation in the skin is 



Acute Atropine Paralysis 541 

interfered with by the lesion in the cord, and, moreover, it is much more 
difficult to test the sensations of an infant six or eight months old than it is 
those of an adult. The functions of the sphincters of the bladder and rectum 
are rarely interfered with. 

The irritability of the muscles to the faradic current becomes lessened 
■during the course of the first week or ten days, and is usually entirely 
lost in those muscles where a permanent paralysis has taken place, and 
thus the careful testing of the muscles may be of importance for prognosis. 
To the continuous current the muscle irritability is increasing during this 
period, though it gradually is lessened as the muscles waste, and may dis- 
appear during the atrophic period. The quality of the muscle irritability 
differs from normal, presenting the 'reaction of regeneration' 1 due to the 
degeneration of the nerves to the affected muscles. 

In the majority of cases one limb only is affected, and one group or 
groups of muscles more affected than others ; in some few cases the paresis at 
first involves not only the limbs, but the diaphragm and intercostals. The 
most severe case coming under our notice was the following: A girl of nine 
months was quite well and healthy till June 21 ; she was able to raise her- 
self up in her cradle, and could support herself with help on her feet. She 
was suddenly seized with convulsions in which her face and arms twitched ; 
this was followed by a discharge from one ear, and at the same time she was 
completely prostrated, her voice was hardly audible, she lay in bed perfectly 
motionless, except a rolling of the head from side to side. She was admitted 
to hospital on July 30, when the following notes were made by Dr. Kershaw: 
* She is a well-nourished child ; lies in bed quite helpless ; the lower ex- 
tremities are completely paralysed ; there appears to be some loss of sensation, 
as only the application of the strongest faradic current appeared to cause 
pain. She can bear without crying the contact of a hot spoon, too hot to be 
held in one's own hand ; can move right arm at the shoulder and elbow, but 
not the hand ; the left arm is completely paralysed, though she seems to 
be able to move the fingers slightly. There is paresis of the intercostals, 
respiration mainly abdominal. No reactions to the strongest faradic cur- 
rent were obtained in the legs, some response could be obtained in the 
flexors of the forearm. She died of pneumonia on August 7, forty-seven days 
after seizure.' 

3. The stage of ' regression ' or improvement now commences, the 
improvement continuing for several months : many muscles being com- 
pletely restored, while others become more and more flabby and atrophic. 
In rare instances all the paralytic muscles may recover. The child's health 
at this time is usually good, it is as bright and cheerful as usual, and there is 
apparently nothing amiss with it except its paralysis. The muscles, which 
are gaining in power, respond more readily to the interrupted current than 
at first, while the atrophic muscles fail entirely to react. 

4. After some months improvement ceases, or, at least, any improvement 
which takes place six months after the onset is usually very slight indeed. 

1 'Reaction of degeneration': faradic irritability lost: voltaic irritability altered in 
character, so that closure-contraction occurs as readily, or more readily, with the ascend- 
ing, as with the descending current; and contractions occur more readily when the 

circuit is broken than in the normal State. 



54 2 Diseases of the Nervous System 

The atrophy mostly goes on, and certain contractures, especially affecting, 
the leg below the knee, leading to deformities, are apt to take place. At this 
period it is possible to make a forecast of the amount of paralysis which is 
likely to be permanent, and take stock, as it were, of the real damage which 
has taken place, which is probably much less than at first appeared likely. 
This permanent paralysis may affect a whole limb, though it rarely does this,, 
some groups being entirely powerless, others only slightly weakened or not 
affected at all. 

Sometimes the groups affected are associated together in their actions, as 
when the upper arm type of Erb is present, the deltoid, spinati, biceps, and 
supinators being affected, while the muscles of the forearm, excepting the 
supinators, escape, the lesion in the cord being situated on a level with the 
fifth and sixth cervical roots. It is important to remember that the groups 
have no relation to their peripheral nerve supply, such as would be present 
if the paralysis was extra-spinal. Very often the muscles paralysed have 
no relation to one another, being picked out as it were at random. 

In the lower limb the muscles below the knee usually suffer more com- 
plete paralysis than those of the thigh or buttock. The peronei usually 
suffer most, the result being that the heel is drawn up and the foot turned 
inwards (talipes equino-varus) by the unbalanced action of the gastro- 
cnemius ; as time goes on the contracted condition of the calf muscles, aided 
by the shortening of the leg, becomes permanent in consequence of a fibroid 
degeneration taking place, and the foot can no longer be dorso-flexed. In 
the same way talipes valgus may be produced by paralysis of the tibialis 
anticus, more rarely talipes calcaneus by the paralysis of the gastrocnemius. 
Both legs below the knee may be paralysed, both extensors and flexors ; and 
the patient cannot stand, but progresses by crawling on his hands and knees,. 
dragging his wasted legs after him. 

Of the thigh muscles, the rectus, vasti, and adductors are more often 
paretic than the hamstrings, and thus flexion of the knee may result and be- 
come permanent. The gluteal muscles and rotators of the hip are often 
weak, so that the child in walking gives way at the hip. 

In the upper extremity the muscles of the shoulder suffer most frequently, 
the deltoid being especially prone to attack ; usually the supra- and infra- 
spinati, biceps, triceps, and supinators are associated together : in such cases 
the shoulder droops from the weight of the arm, and the head of the humerus 
may slip readily out of its socket. The serratus magnus, pectoral muscles, 
and intercostals may also be affected. The forearm muscles, both extensors 
and flexors, together or singly, may be affected ; less often those of the hand. 
Contractures are less often present in the arms than in the legs. 

The muscles of the spine, sacro-lumbalis, &c, and those of the neck and 
diaphragm, are rarely permanently paralysed. Lordosis is present if the 
sacro-lumbalis is weakened. Lateral curvature may be present. 

The paralysed muscles are always atrophied, though at times much sub- 
cutaneous fat may give a delusive appearance of solidity to the muscle. In 
the most wasted muscles there is a complete loss of faradic irritability : there 
is usually more or less present in those only partially paralysed. The irrita- 
bility to the continuous current gradually disappears as atrophy progresses, 
and in the wasted muscles becomes completely lost. 



Acute Atrophic Paralysis 543 

Arrest of developmeitt of the limbs which are paralysed also takes place ; 
the bones appear to grow more slowly on the paralysed side. Other bones 
such as the ribs and pelvis may be affected. The joints often become more 
movable from relaxation and stretching of the ligaments, as well as from the 
loss of support afforded by the normal muscles ; the articular ends may be- 
come deformed. The circulation through the skin of the paralysed limbs 
becomes slow, the surface has a blue or purplish appearance and feels cold 
to the touch. Chilblains and ulcers are apt to form on the paralysed limbs 
and be slow to heal. The bones themselves frequently degenerate ; in 
some cases little true bone may remain, fat taking the place of the 
osseous tissue. Injuries, operative or accidental, of such limbs are slow 
in healing ; on the other hand, acute inflammations rarely attack the tissues. 
Pathology. — There is an acute inflammation, the greatest stress of which 
falls on the anterior cornua of the grey matter in the cervical and lumbar 
enlargements. In severe cases the grey matter of the dorsal cord is also 
affected. There is strong reason to believe that, in severe cases at least, the 
inflammation is not confined to the anterior cornua, but involves more or less 
the whole cord ; but the principal damage caused by the effusion of blood and 
inflammatory products occurs in the most vascular part of the cord, and this 
is in the anterior cornua where the large nerve cells are situated. During the 
acute stage of the attack, where there is perhaps a high temperature and con- 
vulsions, there is probably an inflammatory engorgement of the whole cord, 
possibly of the whole of the nervous centres : then an exudation of inflam- 
matory material takes place which leads to both temporary and also per- 
manent damage to the motor cells in the anterior cornua of the cervical or 
lumbar enlargements. During the next few months an absorption of inflam- 
matory material and perhaps also repair of damage by the formation of new 
nerve fibres or cells goes on, while a certain amount of muscular power which 
has been lost is regained. Finally a sort of cicatrisation or shrinking takes 
place, leaving a permanent paralysis of the muscles supplied by the nerve 
centre which has been destroyed. 

Very few observations have been made on the cords of those dying during 
the acute attack or at the onset of the paralysis. In Drummond's case, 1 that 
of a child of five years who died in a few hours, the vessels supplying the 
anterior horns were distended with blood, the microscope showing minute 
extravasations of blood and changes in the nerve elements. A case re- 
corded by Charlewood Turner, dying six weeks after the attack, showed 
softening of the anterior horns, spots where the grey matter had undergone 
complete degeneration, and an exudation of leucocytes had taken place from 
the vessels. In our own case, p. 541, similar changes were visible in the grey 
matter of the lumbar, cervical, and dorsal portions of the cord, and changes 
such as effusion of leucocytes from vessels were noted in the white matter, as 
well as the grey. Moreover, even in the medulla it was evident that an 
engorgement of the vessels had taken place. 

Degenerative changes take place in the nerves which are connected with 
the damaged centres in the cord : the muscles also waste ; their connective 
tissue becomes hypertrophicd, so that in extreme cases very few muscular 

1 Brain, April iSS; 



544 Diseases of the Nervous System 

fibres are left. The muscles which antagonise the paralysed muscles mostly 
.also waste, their muscular fibres becoming replaced by connective tissue. 

Diagiiosis. — The diagnosis during the acute attack is always difficult, 
mostly impossible ; the fever, delirium, and convulsions sometimes present 
naturally suggest some cerebral disease such as meningitis or the onset of 
scarlet fever or pneumonia. It is only when paralytic symptoms present 
themselves that the diagnosis is made ; even then the paralysis may be over- 
looked, especially in young children, it being supposed that the child is 
-simply weak as the result of the acute attack. When once the paralysis has 
set in, diagnosis is easy, though when paraplegia is present the distinction 
between transverse myelitis of the lumbar region and polio-myelitis may 
not be easy. In transverse myelitis there will be certainly loss of sensation ; 
this is said not to occur in cornual myelitis, though in the case recorded 
•{p. 541) there was undoubted slight loss of sensation. In transverse myelitis of 
the dorsal region, its commonest seat, there will be no loss of faradic irritability, 
and after a few days or a week the reflexes will return and become excessive, 
.and ankle-clonus can usually be obtained. 

In cerebral paralysis there is no loss of faradic irritability, and no mus- 
cular wasting takes place. 

Treatment. — The treatment of anterior polio-myelitis in the early stages 
is that of an acute inflammatory lesion of the cord. The child must be kept 
as quiet as possible in bed, given a milk diet, and good may possibly be done 
by applying mustard poultices to the spine. If there is fever, aconite and 
bromide of potassium may be given. When the acute stage has passed away, 
and the child is left in a prostrate condition, the greatest care must be taken 
to keep the child at rest as much as possible, all excitement of every kind 
being avoided. It must be borne in mind that, in patients dying, many 
weeks or even two or three months after the onset evidences of the inflam- 
matory lesion may still be found in the cord, and during this period absorp- 
tion of inflammatory material is going on, and the object to be aimed at in 
treatment is to secure the recovery of as much of the damaged cord as 
possible. A" variable amount of nerve tissue has been certainly irretrievably 
damaged, but some of the damage done is recoverable, and, the more the 
general health is maintained and the child kept at rest, the more is it likely 
that recovery will take place. 

It may be doubted if there are any medicines which have any direct 
influence over the nutrition of the cord or directly influence any morbid 
processes going on. Perhaps the most likely drugs to be of service are 
sedatives such as belladonna, and bromides in combination with iron or 
quinine. 

The question of how soon should massage or electrical treatment be 
"begun is an important one, for, on the one hand, the paralysed muscles are 
quickly wasting on account of their nerve centres being damaged, but on 
the other hand the disturbance of the child, the fright and excitement of 
the daily application of the battery, are not unlikely to do harm. The 
application of the battery current is hardly likely to modify or favourably 
influence the lesion in the cord, but it may help to maintain the nutrition of 
the muscles while recovery is taking place in the cord. On the whole we 
are inclined to believe that gentle rubbing or massage of the paralysed 



Acute Atrophic Paralysis 545 

limb or limbs may be practised from the first, and voltaic currents may be 
used within a month or six weeks. It is wise to begin with a very weak current, 
at first using large wetted sponges as electrodes, and frequently interrupting 
the current, which after a few applications should be just strong enough to 
secure a contraction. The application should be made daily for many 
months, especial care being taken to select the paralysed muscles in the limb. 

An important part of the treatment is to encourage the patient to put 
forth as much voluntary power as possible, and he should constantly try to 
use the weakened limb. We believe that systematic attempts to use the 
paretic muscles, combined with shampooing of the limb, are more likely to 
promote recovery than any electrical applications. The circulation in the 
paralysed limb is certain to be slow and defective ; friction of the skin, with 
kneading of the muscles, is certainly beneficial ; while a well-selected series 
of movements attempted on the part of the patient, or carried out by an 
attendant, assists the return of power in the muscles. These measures must 
in most cases be persevered in for many months, if not years, in the hope of 
improvement. 

The paralysed limbs must be warmly clad and carefully protected from 
cold. 

Much may be done in the chronic stage by means of mechanical devices 
such as the application of artificial muscles and splints to correct deformities 
and support the limb. Division of the tendo Achillis, plantar fascia, and 
other resisting structures is often required. For useless flail-like limbs the 
question of excision of joints to procure greater stability, or even of amputa- 
tion, has to be considered. Vide also chapter on Talipes. 



Peripheral Neuritis 

We have already referred to the fact that a form of paresis or paralysis 
may accompany or follow an attack of diphtheria. The ptomaines present 
in the blood give rise to a degeneration or neuritis of the terminal nerve 
fibres. While it is far more common after diphtheria than any other disease, 
it occurs also after influenza and some other zymotic diseases. Occasionally 
peripheral neuritis accompanies rheumatism and chorea, and we have also 
noted it when no history could be obtained of any disease preceding the 
paralysis. That it occurs in connection with influenza we feel sure ; in one 
case coining under our notice paresis of the ciliaris muscles occurred in 
a boy aged seven years during convalescence from influenza, and where 
diphtheria could be excluded with certainty. In another case of ours 
of pneumonia which appeared to be clue to influenza, paresis of the inter- 
costals, diaphragm, and extremities supervened during convalescence, which 
ended fatally. 

Myopathies 

I. Pseudo-hypertrophic Paralysis. — Very little is known about the 
etiology of this particular disease. It is apt to run in families, and. strange 
to say, while it affects boys far more frequently than girls, in some 
families it affects the boys only, and in others it affects the girls. In 

X X 



546 



Diseases of the Nervous System 



some cases there is a family history of the disease, and it appears it may 
be transmitted through the female side without the women themselves 
being affected (Gowers). In one of our own cases the patients brother 

was an epileptic, but it rarely happens that any 
family tendency to nervous disease exists. 

Symptoms. — In the majority of cases sym- 
ptoms first make their appearance during the 
second or third year, the child being late in 
learning to walk, the parents attributing this 
to backwardness or weakness. In some cases 
the symptoms of weakness are noted after the 
child has been walking some time, perhaps as 
late as the sixth or seventh year. The early 
symptoms are those of weakness in the legs. 
As Gowers well puts it, ' these children usually 
walk late, often also walk clumsily, fall with 
ease, and rise with difficulty/" If placed upon 
the ground they either cannot get up without 
help, or, what is more likely in the early stages, 
they are obliged to use their hands in rising, 
pushing themselves off the ground and catching- 
hold of chairs or table-legs to help themselves 
up. They walk clumsily, with a swaying gait, 
are quickly tired, and have to be wheeled about 
in a perambulator long after children of a 
corresponding age are running about and 
going walks. 

In other cases the friends pay little heed to 
the backwardness in walking, but are struck 
with the size of the calves or perhaps apparent 
stoutness of the child. At four or five years 
of age, often earlier, the muscular hypertrophy 
is conspicuous. The muscles of the calf are 
strikingly enlarged, firm, and hard ; as are 
usually also the glutei and lumbar muscles — 
less often the hamstrings, extensors of the 
knee, and dorso-flexors of the foot. Of the 
other muscles, the infra-spinatus is, next to 
the calf, the most frequently enlarged, and, 
as Gowers points out, this enlargement of the 
infra-spinatus may be of diagnostic import- 
ance. The deltoid and supra- spinatus are often 
enlarged, the latissimus is mostly wasted, and 
the rule is that the other muscles of the upper 
extremity are wasted rather than hypertrophied. 
In rare cases the masseters and muscles of the tongue are enlarged. 

The muscles, whether enlarged or wasted, are weak, and it is this 
weakness of certain muscles which gives rise to the characteristic movements 
of the child. The waddling gait is the result of weakness of the gluteus 




Fig. no. — A case of Pseudo-hyper- 
trophic Paralysis in a boy of ten 
years ; showing enlarged calves and 
slight talipes equinus. 



P sendo-hyper trophic Paralysis 



547 



medius and extensors of the hip generally. The difficulty in rising from 
the floor is due to the paresis of the extensors of the knees in the first part 
of the act, and the extensors of the hips in the second, the patient assisting 
the extension of the hips by placing his hands on his knees, and ' climbing 
up himself by grasping his thighs alternately with his hands. 

Later in the disease the enlarged muscles contract, the earliest to shorten 
being the calf muscles, so that a talipes equinus is produced. Later on, the 
knee and elbow may become flexed. 

The weakness of the extensors of the hip produces a certain amount of 
lordosis or curvature of the spine with the concavity backwards, the patient 
assuming this position in order to 
maintain his balance. (See figs, 
no, III.) 

In the last stages the patient 
becomes entirely bedridden and 
helpless, partly on account of the 
paresis of the muscles, partly also 
in consequence of the muscular 
contractions producing talipes 
equinus. In this stage the enlarged 
muscles mostly waste, and conse- 
quently lessen in size. The electric 
irritability of the muscles is un- 
affected both to the continuous and 
interrupted current at first; later, 
as the muscular fibre wastes, it 
gradually disappears. The knee- 
reflex, at first normal, gradually 
disappears for a similar reason. 
In children suffering from this 
disease the mind is often weak. 

The progress of the disease 
is slow, extending over many 
years, the patient possibly being- 
helpless and bedridden, having 
almost lost the use of his legs. 
He is even unable to sit up on 
account of the wasting of the 
spinal muscles, but is usually able to use his hands to the last. Death 
is apt to take place from bronchitis ; this was the case in one of our own 
cases who lived to the age of twelve years, the disease haying existed at 
least eight years. In the majority of cases where the disease begins early, 
death takes place soon after puberty, at any rate among the hospital patient 
class ; under the most favourable circumstances, where great care is taken 
of the patient, life may be prolonged to a greater age. The course oi the 
disease appears to be slower in girls than bens. 

Diagnosis. — This is most difficult in young children in the early - 
and in the absence oi typical enlargement oi the calf muscles and infra- 
spinati. A fat, yet weakly, child of three or four years of age, who is late in 

\ \ a 




Fig. in.— Same case as fig. no; showing Hyper- 
trophied Deltoid and Infra-spinati. 



548 Diseases of the Nervous System 

walking and more or less rickety, may somewhat simulate a case of pseudo- 
hypertrophic paralysis in its gait, and in the difficulty of getting up. Usually 
there is sufficient enlargement and hardness about the gastrocnemii to make 
the diagnosis tolerably clear, especially if there is corresponding enlarge- 
ment of the infra-spinatus and wasting of the latissimus dorsi. In the 
absence of muscular enlargement, especially if there is wasting, the disease 
may be confounded with idiopathic muscular atrophy ; but the latter disease 
is rare before puberty, is apt to affect the face and hands, and to avoid the 
calf muscles. A fragment of muscle may be obtained, and muscular atrophy 
can be excluded, if there is an excess of fibroid and fatty tissue present. 

Prognosis. — The cases slowly, but surely, get worse ; the weakness year 
by year increases, though a certain amount of temporary improvement may 
take place. We have seen cases which we believe to have been examples 
of this disease in a mild form get entirely well. 

Pathology. — The disease has been conclusively proved by the careful 
examinations of Gowers and others to be primarily a disease of the muscles,, 
and if changes take place in the spinal cord they are only secondary. There 
is an overgrowth of connective and fatty tissue ; it is the latter which forms 
the enlargement of the muscles, and it is the absence of muscular fibres 
which renders them weak. The shortening which takes place is due to the 
contraction of the fibrous tissue. 

Treatment. — Medicines, except those which are likely to improve the 
general health, are of little use. The treatment which has proved itself of 
the greatest use in checking the progress of the muscular wasting is exercise 
of the affected muscles by well-arranged movements, which the patient is 
encouraged to perform, and friction, with passive movements, so as to pre- 
vent shortening of the muscles. We have certainly seen cases which have 
been admitted to hospital improve in no inconsiderable degree under this 
treatment. It is needless to say it must be systematic, and carried out with 
the greatest patience if it is to be successful. 

2. Juvenile Form of muscle Atrophy (Erb). — This form of muscle 
atrophy resembles in some respects pseudo-hypertrophy of muscles, and some 
cases occur in which it may be difficult to say to which class they belong. We 
note here also the tendency to run in families. There is weakness and 
wasting of certain groups of muscles. The upper-arm muscles are usually 
first affected— namely, the biceps, triceps, and supinator longus ; the lower 
part of the pectoralis major and minor, and also the serratus, trapezius, 
latissimus and rhomboidei often also suffer more or less atrophy. The 
deltoids, infra and supra spinatus, usually escape ; in some cases they have 
been described as hypertrophic. The muscles of the forearm and hand 
usually escape. In the legs, the quadriceps, the flexors of the hip, and glutei, 
the peronei and tibialis anticus may be affected. The muscles of the spine, 
especially the sacro-lumbalis, may be wasted more or less. The electric 
irritability of the muscles is lessened in proportion to the wasting. There is 
no reaction of degeneration. The disease is essentially chronic. 

3. Infantile Muscle Atrophy of the Face IVIuscles (Landouzy, De- 
jerine). — This form is closely related to (2), if not actually belonging to the 
same class. This disease appears to be almost entirely observed in children. 
There is wasting of the muscles of the face, especially the orbicularis oris, 



Myotome 549 

zygomatics, and frontalis. The expression of face is peculiar, and there is a 
curious alteration of expression if the child laughs or smiles, on account of the 
paralysis of the zygomatics which elevate the angles of the mouth. On account 
of the weakness of the orbicularis oris, the lips are separated and the lower 
lip protrudes. The tongue, eyeball-muscles, and muscles of mastication 
escape. The course, like that of other diseases of this group, is chronic and 
progressive. 

Myotonic. Thomsen's Disease 

The first symptoms of this rare disease are first observed during child- 
hood, and apparently persist through life. The disease is apt to affect 
several members of the same family, and can be traced back through several 
generations. The characteristic symptom is that whenever the patient 
attempts to move, the muscles assume a condition of cramp or tonic spasm. 
After a few attempts to use his limbs the patient succeeds in gaining 
command of the muscles, and the spasm does not return till after a period of 
rest. No treatment appears to be of any use. 



550 Diseases of the Genito-urinary System 



CHAPTER XXIV 

DISEASES OF THE GENITO-URINARY SYSTEM 

Congenital Anomalies of the Kidneys. — The principal malformations 
of the kidneys found post mortem are : (i) Absence, or only a trace, of one 
kidney, with hypertrophy of the other ; (2) ' Horse-shoe' kidney, in which the 
two kidneys are united by a bridge of kidney tissue, giving the organ a horse- 
shoe shape. The kidney is placed with its convexity downwards, the ureters 
passing down behind the bridge. (3) The kidneys are frequently found 
tabulated, the surface being deeply fissured, dividing them into ' lobules,' 
as in the fcetal state. (4) The kidneys may be displaced or more or less 
movable. 

These abnormalities, though of extreme importance in reference to opera- 
tions on the kidneys and the diagnosis of abdominal tumours, need not be 
further referred to here. Obliteration of one ureter, partial or complete, may 
give rise to hydronephrosis and require operation, as in a case reported by 
Tuckwell and Symonds of Oxford. 1 Incontinence of urine from an abnormal 
opening of the ureter just in front of the meatus urinarius has also been 
met with.' 2 

Addison's Disease. Tuberculosis of the Adrenals. — Addison's dis- 
ease occurs occasionally in boys after puberty ; it is very rare before this 
epoch. Dr. Pye Smith has recorded a case in a boy of fourteen years, and 
Monti has collected eleven cases in children from three to fourteen years of 
age. Tubercles, both caseous and grey, are frequently present in the supra- 
renal capsules of children dying from general tuberculosis, without any 
symptoms occurring during life. 

Kaematuria. — Blood is present in the urine in a variety of conditions, 
in general diseases as well as in local, and a difficulty may not infre- 
quently be experienced in determining the source from which the bleeding 
takes place. 

Hsematuria or hemoglobinuria occurs at times in infants a few days or 
weeks old, who are also jaundiced ; epidemics of such cases have been de- 
scribed by Winckel and Bigelow as occurring in lying-in hospitals (p. 28). 
Two fatal cases, in which haemoglobinuria was present in infants five months 
and eight months old respectively, have been described by Hirschsprung. 3 
In both cases the symptoms supervened suddenly ; there was cyanosis, dark 
albuminous urine and feverishness ; in one of the cases there was dyspncea 

1 Lancet, vol. ii, 1882, p. 141. 

2 Madden, American Obstet. Jour. July 1884. 

5 Congres international periodique des Sciences Mddicales, 1884 : section de Pediatric 



Hcematuria 5 5 1 

(uraemic) and tetany of the hands and feet. The ftost-i7iortem showed that 
all the organs were of a dirty brown colour, and the blood in the body had 
undergone a remarkable change. Similar cases have occurred from poison- 
ous doses of chlorate of potash, but neither of these cases had been taking 
this salt. 

Haematuria occurs occasionally in wasted infants and young children 
from thrombosis of one of the renal veins, a consequent hsemorrhagic infil- 
tration of the kidney taking place. 

We should say the commonest cause of haematuria in infants and children 
under two years of age is the scorbutic condition described in connection 
with rickets (p. 401). In some cases hematuria is the first symptom, 
usually spongy gums are present, but periosteal tenderness may be absent. 
Haematuria may succeed the tenderness and immobility of the limbs. The 
infant is generally pallid and is more or less markedly rickety. The nurse 
probably notices that the urine stains the napkin it may be bright red, or in 
milder cases a yellowish-red colour. If the urine is passed into a vessel a red 
sediment of blood corpuscles settles to the bottom, leaving the fluid portion 
tolerably clear. 

We can call to mind several instances where infants suffering from 
haematuria from this cause were sounded for stone ; it is needless to say that 
no stone was found, and they quickly got well when their diet was changed. 
It is uncertain whether the blood oozes from the kidneys or bladder. In 
these cases there is no nephritis, only a passive oozing of blood. 

Haematuria may be the first symptom of haemophilia, and in any case 
where the diagnosis is doubtful the family history should be inquired into 
for similar cases. 

Haematuria is often associated with purpura and may occur in acute cases 
of variola, diphtheria, or typhus, resulting from the rapid blood change which 
takes place. 

Haematuria may be present in acute nephritis ; in this case the urine is 
usually of a smoky tint, or more the colour of porter, but in some cases the 
colour may be bright red from the large amount of blood which it contains. 
We have seen haemorrhagic nephritis following scarlet fever, diphtheria, and 
pneumonia. A microscopical examination of the deposit which falls to the 
bottom of the glass after the urine has stood for a while will show blood and 
epithelial casts in cases of nephritis. 

Blood in the urine also occurs in cases of renal or vesical calculus, more 
rarely in tubercular kidney, sarcoma of the kidney, and vascular growths in 
the urethra or bladder. 

Poisoning by chlorate of potash, cantharidcs, or turpentine as a cause oi 
haematuria must not be forgotten. 

Treatment. — The treatment necessarily depends upon the cause, and the 
history of the case, and other symptoms apart from haematuria, must be care- 
fully considered. It is important to exclude stone in the bladder as the 
cause of haematuria, and in all cases where the cause oi the blood in the 
urine is doubtful it is wise to explore the bladder with 1 sound. Hcematuria 
may be the only symptom of the presence o\ a stone. In haematuria depend- 
ing upon an impoverished condition o\ blood the most important part of the 
treatment consists in improving the condition o( the general health. Meal 



552 Diseases of the Genito-urinary System 

juice, orange or lemon juice, with dialysed iron or the perchloride, may be 
given. 

Styptics may also be given, though we have frequently been disappointed 
with their action. Of these, ex. hamamelis liq. (U.S. P.), in 5-15 minim doses, 
may be given every four hours, and continued for some days. Gallic acid 
\-2 grains, with aromatic sulphuric acid, is sometimes efficacious where 
hamamelis fails. Spirits of turpentine ^-3 minims in mucilage, or liquid 
extract of ergot 2-10 minims may be tried. 

Acuts pyelitis is certainly not a common disease in infants or children. 
We have, however, seen several cases of acute illness in infants or young 
children accompanied by a high temperature of an intermittent type, and 
after the attack has lasted several days it has been noted that the urine con- 
tained pus ; the nurse having called attention to the fact that there was 
something unusual in the way in which the urine stained the diapers. Dr. S. 
J. Gee 1 has recorded a similar case in an infant of nine months. Dr. Emmett 
Holt 2 records three such cases in infants of eight months, nine months, 
and fourteen months respectively. The temperature in one of his cases ran 
high, and there were distinct 'chills' in which the infant became blue. 

What is the exact nature of these cases, and whether the pyelitis is 
primary or secondary to some other disease, it is difficult to say. All the 
recorded cases ended in recovery. 

Lithaemia. — Infants and children frequently pass uric acid in their urine, 
the uric acid being seen as a sandy deposit in the chamber vessel. The 
cause of this is mostly uncertain. Large quantities are often passed during 
convalescence from scarlet fever, not infrequently in cases followed by 
nephritis. 

We have sometimes seen cases in which uric acid has been passed in 
large quantities : in one case coming under our notice the urine would be 
clear for a while, and then, especially after rough movements, as in romping 
or riding a pony, urine thick with uric acid crystals would be passed. Uric 
acid is sometimes passed more copiously with the urine voided with a stool, 
giving at first the impression that the uric acid has come from the bowel, 
when apparently the straining at stool has caused the dislodgment of uric 
acid deposited in the bladder or pelvis of the kidney. In lithaemia a 
restricted diet should be given, and citrate of potash and lithia may be 
prescribed. 

Tumours of the Kidneys. — Swellings which occur in the region of one 
of the kidneys may be due to one of the following causes : 

(1) New growth. (2) Tubercular or other abscess in the kidney. 
(3) Hydro-nephrosis. (4) Perinephritic abscess. 

(1) Renal New Growths. — In the majority of cases a new growth in- 
volving a kidney is a round-celled sarcoma which begins outside the kidney, 
gradually displacing and compressing the kidney itself. It is difficult to say 
exactly where these growths begin : presumably in lymphatic tissue. In the 
minority of cases the new growth appears to begin in the kidney itself— at 
least no trace of the kidney can be found post mortem, but traces of kidney 
structure may be found scattered through the tumour on microscopical 
examination. 
1 Brit. Med. Jour. November 17, 1883. 2 A chives for Pediatrics, November 1894. 



Renal New Growths 



3 



In some cases the tumour is a myo-sarcoma, or in other words it is a 
round-celled sarcoma with a variable quantity of striated muscular tissue 
and spindle-shaped cells. In rare cases the growth consists of alveoli lined 
with columnar epithelium, similar in structure to the cylindrical epithelial 
carcinomas found in the large intestine. It is difficult to say where such 
tumours begin when occurring primarily in the kidney : possibly in the 
remains of the Wolffian body. 

Renal sarcomata are usually soft in 
•consistence, resembling brain substance, 
and frequently contain masses of blood 
clot and altered blood in consequence of 
haemorrhages which take place into their 
substance. They often attain to great 
size, weighing many pounds, and by 
their enlargement displace the other 
organs of the abdominal cavity. The 
liver or spleen is pushed upwards, the 
small intestines are pushed on one sicie 
or posteriorly ; the large intestine, where 
it crosses the tumour, is compressed 
against the abdominal wall (see fig. 1 13). 
The tumour may set up a certain amount 
of chronic peritonitis and contract adhe- 
sions to the intestines and other viscera. 

Renal sarcomata occur most com- 
monly in children under six years ; of 
fifty cases collected by Seibert, forty 
occurred during the first five years ot 
life, twelve being in infants under a year 
old. In a case recorded by A. Jacobi 
a sarcoma was present in the kidney of 
a foetus born dead, and other cases (Sir 
William Roberts and Lloyd Roberts) 
have been recorded in which the tumours 
were present at birth. 

F. T. Paul, 1 of Liverpool, whose 
paper on this subject is the most im- 
portant of those recently published, says, 
' The chief characteristics of congenital 
renal sarcomata are these : 

'(1) They show themselves during the first five years of life, and are 
probably invariably of congenital origin. 

'(2) They arc primarily extra-renal though usually intracapsular. 3 

He points out that they may be bilateral, that they cause death by ex- 
haustion or pressure rather than by urinary lesions, that metastatic growths 
only occasionally occur, but all forms of growth tend to recur after removal. 
The tumours frequently contain striped muscle, embryonic renal tissue, and 
various forms of adult connective tissue. The complexity of the structure ot 
1 Liverpool Med.-Chir, Jour. January 1894. 




Fie. 



girl of 1 



Cylinder Ep'.thelion 



year 



Dr. Hutt 



f Kidney m a 
Mi's case. 



554 Diseases of the Genito-unnary System 

these growths is to be explained by the inclusion within the capsule which 
forms round the embryonic kidney of elements of other neighbouring tissues. 
Mr. Paul describes growths of the ' simple connective tissue type, ; of the 
' complex connective tissue type, 1 and of the ' renal adenoma type.'" 

Except Abbe's recent cases almost all the subjects of these tumours have 
died within a year of operation. 

Symptoms and Course. — In the majority of cases enlargement of the 
abdomen due to the new growth encroaching on the other abdominal organs 
is the first symptom to call the attention of the friends to the case. In the 
minority of cases (one-fifth, Seibert) hematuria is the first symptom occur- 
ring at a variable period before the discovery of a tumour. The swelling is 
first noted occupying the right or left lumbar region, between the ribs and 
the crest of the ilium ; it has a rounded outline, which can be traced down- 
wards, but not into the pelvis, and upwards behind the liver or spleen. By 
palpation it can be separated from the liver or spleen. It moves less freely 
with respiratory movements than an hepatic or splenic tumour does. Per- 
cussion shows that the large bowel lies across superficially to it, but if the 
tumour is large the colon may be compressed and no tympanitic note will 
then be detected. The swelling has a soft semi-fluctuating feel, and on ex- 
ploration with a subcutaneous syringe pure blood is withdrawn. During 
the early stages the patient appears perfectly well, is well nourished, com- 
plains of no pain ; there is no tenderness on handling the tumour. Ex- 
ceptionally pain is complained of ; in some cases it is acute and due to 
accompanying peritonitis. In Seibert's collection of fifty cases hematuria 
was present in nineteen at some time or other during the course. Vomiting 
is an occasional symptom. As the tumour increases in size it distends the 
abdominal walls, the skin becomes smooth and shiny, and is marked with 
large dilated veins. The tumour pushes up the diaphragm, passes perhaps 
beyond the middle line in front, and extends backward to the spine behind, 
sometimes, as in the case fig. 112, forming an enormous abdominal tumour. 
The liver and spleen are frequently enlarged ; the patient gradually ema- 
ciates and has a cachectic appearance ; perhaps the lower limbs become 
cedematous from pressure on the vena cava, and death comes perhaps after 
many weeks of lingering misery. Constipation is often present from pres- 
sure on the colon. 

Diagnosis. — A sarcomatous enlargement of the kidney may be possibly 
mistaken for a hydro-nephrosis, abscess of the kidney, perinephritic, or spinal 
or other abscess. It is less likely to be mistaken for a tumour of the liver 
or spleen. A renal tumour may be distinguished from an hepatic or sple?iic 
tumour by the fact that it moves less with respiration and the colon traverses 
its anterior surface, and moreover the edge of the liver and spleen may usually 
be felt. A congenital hydro-nephrosis, in which the obstruction in the ureter 
is complete, may cause some difficulty in diagnosis ; there would be, how- 
ever, in a swelling of any size, fluctuation transmitted from the abdomen to 
the flank in a hydro-nephrosis, and on exploratory puncture the fluid with- 
drawn would make the diagnosis clear. An abscess in, or scrofulous enlarge- 
ment of, the kidney is rare without a history of pain and tenderness in the 
lumbar region, and without pus in the urine. It is, however, possible that 
these may be absent, and then the rapid growth in the case of a sarcomatous 



Renal New Growths 555 

kidney would m time decide the diagnosis. But a difficulty could rarely 
occur. 

Prognosis. — This is necessarily grave ; though such tumours are chronic 
in their course and the patient may live for many months or even a year after 
the discovery of the tumour. 

Treatment. — As far as we know, no drug influences the progress of the 
growth. Removal of a sarcomatous kidney is usually followed so rapidly by 
recurrence that this, the only possible, treatment is hardly justifiable. 




Fig. 113. — Congenital Renal Sarcoma, from a photograph. (F. T. Paul.) 



Tuberculous Kidney. — Tuberculosis of the kidney is very commonly 
met with in children as part of a geneial tuberculosis. Thus of no fatal 
cases of tuberculosis in the Children's Hospital in the years 1SS1-1SS5 in- 
clusive, in forty-six there was evidence of tubercle in the kidneys in larger or 
smaller amount. Most frequently the lesions are simply scattered grey 
tubercles in the substance or on the cortex of the organ : this was the case 
in thirty-nine instances. 

Much more rarely large masses of tuberculous material are found, or 
occasionally extensive destruction of the papillae and ulceration of the pelvis, 
and sometimes of the ureter. Occasionally calculi are found coexisting with 
tuberculous lesions. 

1 1 is in our experience rare to find children suffering from tuberculous kidney 
apart from a general tuberculosis ; less than half a dozen such cases were 
admitted to the hospital in the five years above mentioned, and genito- 
urinary tuberculosis — i.e. lesions affecting the kidneys, bladder, testes, pro- 
state, vesicuko seminales — is not nearly so common as in adult life, though 
the bladder is not rarely involved. When the tuberculous lesions ot the 
kidney are only part of a general tuberculosis, life is usually destroyed be 
the kidney affection is very far advanced, but whore the disease is limited 
to the urinary tract the whole of one kidney ma\ be destroyed and conv< 
into a mere sac- with hardly a trace of secreting structure left, Ver) com- 
monly both kidneys are affected together, but in a considerable proportion of 



556 Diseases of the Genito -urinary System 

■cases one organ alone is attacked, and under such circumstances life may be 
prolonged, or even recovery may take place, the damaged kidney shrinking, 
and ceasing to cause irritation ; the whole of the work then devolves upon its 
fellow. All stages of disease, from the presence of a few tubercles to that of 
cheesy masses, and on to complete disorganisation, may be found. Peri- 
nephritic abscesses develop in some cases. 

Symptoms. — When the kidneys are the seat of miliary tuberculosis there 
are usually no symptoms whatever pointing to disease of those organs : thus 
of thirty-nine cases of this form of disease, in only one was there even albu- 
minuria, and that to a very slight degree. When, however, tuberculous 
ulcers or abscesses exist, pus, mucus, and large quantities of albumen may 
be found ; but the only instance in which hematuria existed in the forty-six 
cases of tuberculous kidney we have examined was one in which calculi 
coexisted with the tubercle, and undoubtedly the presence of blood in the 
urine points to calculi rather than to renal tuberculosis. 

Pain and tenderness are only prominent symptoms when there is exten- 
sive disease and the pelvis becomes distended with pus and tuberculous 
material, and the same statement holds good of enlargement ; it is only in 
the later stages of the disease that any palpable enlargement of the kidney 
takes place. 

Frequent micturition is rather a symptom of tubercular cystitis than ot 
renal disease, and where it exists with evidence of tuberculosis of the kidney, 
especially if there is tenderness of the bladder and much pain on sounding 
or passing a catheter, it is tolerably certain that the bladder is affected as 
Avell as the kidney. 

The presence of tubercle bacilli in the urine would, of course, indicate 
urinary tuberculosis, though without other evidence it would not show 
whether the disease was renal or not ; unfortunately in most cases of renal 
tuberculosis the bacilli are not to be found until the disease is far advanced. 

When one kidney alone is affected and the ureter becomes blocked with 
caseous material or granulations, pyro-nephrosis may develop and form a 
large abdominal tumour in which fluctuation may be detected : in such 
cases more or less fever will also be present and the diagnosis will be easy. 
It is in the early stages that a doubt arises. If there is a tubercular 
history or evidence of tubercle elsewhere, if the trouble is of only a few 
months' duration and there is pus, but little or no blood, in the urine, 
and if there is a gradual failure of health, the disease is probably renal 
tuberculosis. 

Treatment. — In cases of miliary tubercle nothing, of course, can be done 
for the renal affection. Where pyelitis exists medicine can do something : 
.the urine should be kept unirritating by the use of diluents and boracic acid 
.(two- or three-grain doses in half an ounce of peppermint water) ; alkalies such 
as carbonate of potash or liquor potassas, or the citrate of potash with hyos- 
cyamus, will also be found useful. If there is lumbar pain and tenderness, with 
palpable enlargement of the kidney, and the symptoms do not subside under 
medicinal treatment, nephrotomy by the lumbar incision should be performed 
and the kidney drained. If on exploration the kidney is found entirely dis- 
organised, and there is evidence from the amount and quality of the urine that 
the other kidney is sound and efficient, a trial should be given to simple drain- 



Renal Calculus 557 

age ; but, should the discharge not decrease, and should the health be failing, 
removal of the affected kidney is called for. This, however, clearly can only 
be justifiable if the other organ is working well, and if the bladder or 
viscera are affected nephrectomy would be probably useless. If removal of 
the kidney is decided upon, it should be done before the health is too much 
broken down, and the lumbar operation should be the one selected. We have 
only once met with a case in a child calling for either nephrotomy or nephrec- 
tomy, so that we do not think suitable cases can be common. 

Hydronephrosis is not very rarely met with in children, and may be 
congenital or the result of partial blocking of the ureter by a calculus or 
cicatrix. Complete obstruction of the ureter appears to lead usually to 
atrophy of the kidney rather than to hydronephrosis. 

The dilated kidney forms a tumour which has characters like those of 
the solid renal growths, except that fluctuation may be felt in it. The history 
is, however, often of longer duration than is the case in solid tumours, which 
usually prove fatal in less than eighteen months. Occasionally the fluid of a 
hydronephrosis is discharged by the ureter, in which case the swelling will> 
of course, vary in size. 

Treatment. — Hydronephrosis should be treated by incision, which is best 
performed in the lumbar region. The fluid which escapes has usually the 
characters of clear dilute urine. The kidney should be drained for some 
time, and only after failure of this treatment should nephrectomy be 
thought of. 

Renal Calculus. — Stone in the kidney is, like stone in the bladder, a dis- 
ease much more commonly met with in some localities than in others ; it is, 
however, apparently relatively rare in children, and when it does occur it is 
seldom that the symptoms are as severe or characteristic as they are in the 
case of adults. It appears that the majority of calculi formed in the kidney in 
children pass down to the bladder without giving rise to any severe symptoms 
of renal colic. Should, however, a stone form in the kidney and be retained 
there, it may give rise to pain, local and radiating, pyuria, frequent mictu- 
rition, tenderness on pressure over the kidney, with rigidity of the lumbar 
muscles, retraction of the testis, vomiting, and above all to haematuria : this 
last is the most characteristic symptom of calculus, and in the absence of 
nephritis renal haematuria is probably due to calculus, though occasionally 
intermittent haematuria is met with without there being any proof of 
the presence of a stone. We have only on two occasions had to per- 
form nephrolithotomy in children. Both recovered satisfactorily from the 
operation. 

In a few cases, if the disease goes on, pyo-nephrosis may be set up, and 
the kidney will then form a tumour perceptible to the touch. 

Treatment. — Should medicinal treatment, which is the same as that for 
tubercular nephritis, fail to give relief, the kidney should be exposed by the 
lumbar incision and explored by puncture with a needle ; if the calculus is 
struck, a director is passed along the needle, and the kidney opened along 
its convex surface and the calculus removed. If the needle fails to find the 
stone, the kidney should be carefully explored with the finger, both by 
palpation upon the surface and subsequently by opening the pelvis and 
examination with the finger and with sounds. Any calculus found should 



558 Diseases of the Genito-nrinary System 

be removed and a drainage tube passed up to the surface of the kidney. 
The wound is then treated on ordinary principles, the tube being 
gradually shortened. If the kidney is healthy and the ureter patent, 
the wound will probably speedily close entirely ; if, however, the ureter 
is blocked, or there is much destruction of the kidney, discharge may go 
on indefinitely, and it may be necessary to remove the organ in order to 
obtain healing of the wound. Before nephrectomy is thought of, however, 
care must be taken to ascertain that the other kidney is capable of doing 
sufficient work. For further details we must refer to the works of Morris, 
Bruce Clarke, and Newman ; also to papers by one of the present writers in 
the 'Medical Chronicle' for 1886-7-9-94. 

Acute nephritis. — Acute inflammation of the kidneys occurs much less 
frequently as a primary than as a secondary disease. The kidneys are 
fortunately not so prone to take on inflammation as the lungs, possibly be- 
cause they are less exposed to cold and they are out of reach of the micro- 
organisms present in the air. They are, however, easily irritated by toxic sub- 
stances present in the blood, and epithelial and other changes are readily in- 
duced in the course of various diseases such as scarlet fever, diphtheria, and 
in all kinds of septicaemia. 

Acute nephritis does, however, occur as a primary disease, or at any rate 
in patients who, as far as we can ascertain, have not suffered from any ante- 
cedent disease, and who were in perfect health up to the time of the attack. 
Thus we find a schoolboy who has never had scarlet fever and has been 
apparently well, has a shivering fit, voids albuminous and perhaps dark urine, 
and passes through a typical attack of acute nephritis indistinguishable from 
post-scarlatinal nephritis. In other cases the commencement of the attack 
is more insidious, and the course more subacute than acute. In rare cases 
acute nephritis occurs during infancy apparently as a primary disease ; and it 
is needless to say that it may be readily overlooked, as the urine of infants 
is not often examined unless special attention is called to it on account 
of its staining the napkin. If there is associated broncho-pneumonia or 
gastro-intestinal disturbance, it is still more likely to be overlooked. The 
difficulty of diagnosis in such cases is not always overcome by a post-mortem 
examination, inasmuch as we may find pale kidneys with more or less 
marked parenchymatous changes in infants who have died of enteritis, septic 
pneumonia, and other acute diseases. It is by no means easy always to say 
when sections of kidney are examined microscopically, whether such changes 
as desquamation of the epithelium are pathological or accidental, or whether 
there is slight proliferation of the epithelium or not. We must emphasise 
the importance of examining the urine in all cases of serious illness in infants 
accompanied by fever, especially if no cause for the illness can be found. At 
the same time we deprecate the too frequent use of the catheter for the pur- 
pose, as urethritis or cystitis is readily set up. 

Reference has already been made to acute nephritis (p. 264) when speak- 
ing of scarlet fever, as acute nephritis occurs more frequently during con- 
valescence from this fever than after any other disease. It is well to bear in 
mind, however, that nephritis may occur after some other febrile states, such 
as diphtheria, varicella, typhoid fever, vaccinia and eczema. These febrile 
conditions appear to leave behind an irritable kidney which is liable to take 



Acute Nephritis 559 

■on an acute inflammatory state. It must not be forgotten that nephritis may- 
follow mild attacks of scarlet fever ; the primary fever may have been over- 
looked by the friends, especially if the latter are unobservant or ignorant ; 
and in any patient coming under notice for the first time, suffering from 
acute nephritis, the history of the case should be carefully inquired into and 
the child's skin examined for any traces of desquamation. 

Acute nephritis occurring during convalescence from scarlet fever, or as a 
primary disease, is usually an inflammatory lesion of the croupous pneumonia 
type. There is an inflammatory engorgement of the blood-vessels, and, as a 
. result, a choking of the tubules by the exudation of liquor sanguinis, and 
usually of blood corpuscles. As a consequence of this the urine is scanty 
and contains fibrinous casts, blood corpuscles, albumen, and much epithelial 
debris. In the less acute cases there is not sufficient blood present to 
discolour the urine. If the inflammatory condition fails to be relieved, 
secondary changes occur, the most important of which consist in a glomerular 
or periglomerular nephritis. The glomeruli become enlarged in consequence 
of a hyperplasia of their endothelial nuclei (Friedlander), or in other cases 
a fibro-cellular growth takes place between the glomerulus and the capsule 
of Bowman ; in either case the result is the same — namely, an obstruction to 
the flow of blood through the glomerulus. Changes in the epithelium also 
take place. As these changes progress the urine becomes more and more 
scanty, and death takes place from either cardiac failure, uraemia, or some 
inflammation of a serous membrane. 

The symptoms and treatment have already been discussed (pp. 265, 271), 
and little need be added here. It is well to bear in mind that cases of very 
different severity may be met with : in some cases the engorgement of the 
kidney is extreme, and variable quantities of urine are passed, containing 
large quantities of blood and albumen. In other cases there may be mai"ked 
anaemia, much general oedema, scanty urine, with no albumen or only a trace, 
and we may be left in doubt if the case is really one of nephritis, or whether 
the oedema is simply due to a watery state of the blood. .This class of case 
is not uncommon in young children under three years who have recently 
suffered from some acute disease, such as acute diarrhoea or pneumonia ; the 
pallor and oedema present suggest acute nephritis, but an examination of 
the urine possibly gives negative results as far as albumen is concerned. 
In some of these cases we have failed to find any evidence of nephritis on a 
microscopical examination of the kidneys. 

Septic nephritis has been also referred to under the complications of 
scarlet fever (p. 264). It is well, however, to bear in mind that such case- 
occur after other febrile states. We have seen a condition of the kidneys 
answering this description occurring apparently primarily, but we have 
always had our suspicions that some cause must have been overlooked. 

Acute Toxic Nephritis, Parenchymatous Nephritis,- In diphtheria, 
malignant endocarditis, zymotic diarrhoea, and any disease in which there is 
ptomaine poisoning, there is albuminuria, and certain changes in the kidney 
are found after death. This is especially so in diphtheria. We have already 
referred to the albuminuria which so frequently occurs in the course of this 
disease, and also to the fact that in some cases, especially in the malignant 
ones, the urine becomes more and more loaded with albumen while becoming 



560 Diseases of the Genito -urinary System 

more scanty, and complete anuria may take place twenty-four hours or forty- 
eight hours before death. Unlike scarlatinal nephritis there is rarely oedema,, 
muscular twitchings, or uraemic convulsions, but coma usually precedes death. 
On post-mortem examination of the kidneys of those dying from diphtheria, in 
most cases the kidneys will be found to be hyperasmic and slightly enlarged, 
the cortex being pale, the medullary portions congested. The principal 
microscopical changes occur in the epithelial cells, which are swollen and 
granular. A few fibrin cylinders and blood cylinders are sometimes present. 
No very marked changes sufficient to account for complete anuria have been 
found in the kidneys of those dying with total suppression of urine. It is 
possible, as has been suggested, that the anuria is due to a peripheral neuritis 
of the abdominal sympathetic, or that portion of the system which regulates 
the local tension of blood in the capillaries of the kidneys. 

Chronic Nephritis. — We cannot too strongly emphasise the necessity 
of examining the urine from time to time of children who have recently had 
scarlet fever, especially if they have suffered from scarlatinal nephritis. It 
is not enough to find that on one or two occasions the urine is free from 
albumen in order to declare them well. Nephritis, however mild, renders 
the kidneys liable to attacks, and these subsequent attacks may readily pass 
into a chronic nephritis in which organic changes take place and irretrievable 
damage is done. There may be an albuminuria which is intermittent, and 
in consequence a slight kidney affection is liable to be overlooked. We 
have known children who had suffered from nephritis and who were ap- 
parently quite well pass urine free from albumen during the night or when 
they were kept in bed, but albumen at once appeared in the urine when 
they got up, and especially if they went out of doors. In such cases an 
acute attack is readily set up, with attendant anaemia and dropsy. The 
history of a chronic nephritis is the history of a series of acute or subacute 
attacks, followed by a period of apparent health perhaps extending over 
many years. No doubt in a certain proportion of cases recovery eventually 
takes place, but in others the kidneys become hopelessly damaged by fatty 
and fibroid changes, and they eventually succumb. In many of these cases 
the progress is exceedingly insidious ; it is only when the friends have their 
attention called to the puffy face or oedema of the feet that medical advice 
is obtained. 

In a typical case of subacute or chronic nephritis the appearance of the 
patient at once establishes the diagnosis— the bloated, puffy, pallid face is 
characteristic. The abdomen is distended, being tympanitic over the air- 
containing intestines and stomach, dull and fluctuating in the flanks from 
the presence of fluid. The scrotum is cedematous, the skin everywhere pits 
on pressure, especially on the dorsum of the feet. There is frequently 
headache and vomiting or nausea. The pulse is usually slow and of high 
tension, but in children the high-tension pulse of Bright's disease is less 
marked than in adults. The heart cavities become dilated, the apex beat is 
diffused and tends to become displaced outwards beyond the left nipple line. 
Possibly the urine is scanty, contains many casts, and is loaded with 
albumen. Gradual improvement takes place till the patient is fairly well 
again, and the urine free, or nearly free, from albumen. In other cases they 
remain for months in practically the same condition, the amount of albumen 



Chronic Nep J iritis 56 1 

and dropsy varying from time to time. Gradually perhaps there is in- 
creasing dropsy, so that the patient becomes waterlogged. The face, lower 
•extremities, and scrotum are extremely cedematous, and the peritoneal cavity 
distended with fluid, while the sickness is very distressing. Dyspnoea 
is usually a marked symptom, and the patient has to be propped up in bed. 
Finally the patient lapses into coma, which marks the beginning of the 
•end. The urine is often reduced in amount to one or two ounces in twenty- 
four hours. Uraemic convulsions are common at the last. 

In such cases a ' large white kidney' is found post mortem ; sometimes 
the kidneys are enormously enlarged. In one of our cases (a girl of twelve 
years) the two kidneys weighed together 22 f ounces, and one measured six 
inches in length. Such kidneys show the epithelium infiltrated with fatty 
drops, and various fibroid changes, especially around the glomeruli, many 
of the glomeruli having been strangulated by a surrounding fibroid growth. 

The 'granular contracted kidney' is rare in children ; we have seen but 
two cases, and these came under observation only a few days before death. 
Both occurred in girls, one aged 11^- years and the other 10J years. In 
the former case there was only a history of two or three weeks' illness 
before admission to hospital, but the history was imperfect ; she had never 
had scarlet fever ; when admitted there was much oedema and dyspnoea ; the 
urine was of sp. gr. 1015, containing half albumen — she passed 800-1000 cc. 
•daily. At the post-mortem the right kidney weighed 2.\ oz. and the left f oz. 
The left was a mere vestige of a kidney ; the capsule of the right was ad- 
herent, the surface granular, the cortex was narrow, and, in short, the kidney 
was an extreme example of a granular contracted one. The ureters were 
•dilated. 

The other case (girl \o\ years) was admitted to a surgical ward for rickety 
•deformity of the tibia. There was a history for two years before of thirst, 
headaches, and frequent passage of urine, especially at night. On admission 
there was urgent dyspnoea, for which no cause could be found ; she gradually 
passed into an unconscious state, and died twenty-four hours after admission. 
No urine was obtained, she having passed it into bed. At the post-mortem 
the kidneys were typically granular and contracted ; they together weighed 
1 \ oz. only, and measured two inches in length ; the capsules were adherent, 
the surface granular, and the cortex surface wasted. 

Treatment — In chronic albuminuria the patient must be rigidly pro- 
tected from cold, as the least chill is liable to lead to an acute attack. Bed 
is the best place as long as albumen is present in the urine. A simple un- 
•stimulating diet is necessary, milk forming the staple food, with arrowroot, 
ground rice, or other light puddings. Meat is best avoided as long as the 
•urine is albuminous. When oedema is present, and the urine scanty, hot air 
or vapour baths should be given daily, while the kidneys are acted on by 
salines, such as tartrate of potash, or by resin of copaiba, digitalis, or squills. 
During convalescence tr. ferri acetatis may be given with digitalis. Vomit- 
ing is best treated by saline purgatives and peptonised milk gruel in small 
-quantities (F. 30). 



o 



562 Diseases of the Genito-urinary System 



CHAPTER XXV 

DISEASES OF THE GENITOURINARY SYSTEM — continued 

Stone in the Bladder in children is, as in adults, a much more common 
disease in some localities than in others. It may occur at any age, and a 
congenital case even has been recorded. The symptoms vary much in 
severity ; sometimes but little pain or trouble is caused by the stone, at other 
times the distress is constant and severe. The causation of calculus need 
not be discussed : there is little evidence that any particular diet has any 
active share in producing it. 

Symptoms. — There is usually pain referred to the end of the penis, or to 
the hypogastrium or perinaeum ; the pain is most severe towards the end of 
micturition, but when there is cystitis is nearly constant. Passage of blood 
in the urine, usually at the end of micturition, is a very frequent though not 
absolutely constant sign ; frequent micturition and inability to retain the 
urine are almost always present. The straining efforts to empty the bladder 
often give rise to prolapse of the rectum and hernia. An elongated, ex- 
coriated prepuce, the joint result of the irritating quality of the urine, of 
frequent micturition, and of pulling at the penis to relieve the irritation felt at 
the end of the organ, is usually seen. The urine is muddy, containing pus and 
phosphates in varying quantity ; if no cystitis is present, it may, however, be 
quite clear. "On sounding, the stone is usually felt at once ; it is rare to fir. d a 
stone in children that is not struck by the instrument as it enters the bladder, 
but, as this is not always so. if the other signs of stone are present, repeated 
soundings should be made if the calculus is not found at once. 

E. Owen suggests that sometimes the stone may be lodged in the orifice 
of one ureter ; but, though Dr. Cullingworth and others have recorded such 
cases in adults, we do not know of an instance of this in childhood. 

The most common variety of calculus in children is the uric acid ; next, 
perhaps, comes the form consisting of urates ; if the stone has caused cystitis, 
there may of course be a phosphatic coating, or the whole calculus may be 
phosphatic. Ebstein believes that the uric acid infarcts of newly born 
children form the first stage in calculus production, and that the large 
quantity of uric acid present in fcetal and early life explains the frequency of 
calculi of this substance (' Centralblatt f. Chirurg.' No. 14, 1885). The 
abnormal elimination of uric acid leads to degeneration of epithelium, which 
forms the animal basis of the calculus. 

Calculi in children vary much in size : that is to say, that, as different 
calculi give rise to varying degrees of distress, some of them are allowed 



Stone in the Bladder 563 

to reach a larger size before the child is brought for treatment than are 
others. 

In shape the calculi are usually oval and flattened (uric acid), but spindle- 
shaped stones are often met with: such are those which, while small, so 
frequently pass into the urethra, and, becoming impacted, give rise to re- 
tention of urine. Thus one of these small oat-shaped calculi some day comes 
to lie with one end projecting into the urethra, violent straining to pass urine 
takes place, and the calculus is washed along the urethra and usually becomes 
fixed just within the meatus at the fossa navicularis, since the meatus is the 
narrowest part of the urethra. In other cases the stone is arrested at the bulb 
or in the penile portion of the tube. The symptoms of such an occurrence are 
pain, oedema of the part, retention of urine, and tenesmus ; on examination 
the stone can usually be felt through the urethral wall, or is readily struck on 
passing a sound or probe into the urethra. If the case is neglected, ulcera- 
tion may take place and extravasation of urine : this sometimes occurs very 
rapidly. We have seen fatal extravasation come on in a few hours. When 
this occurs the symptoms are the same as in an adult : pain, swelling of the 
perinseum, scrotum, and penis, constitutional disturbance, and, failing relief, 
rapid sloughing of the tissues. In all cases of retention of urine in a child, if 
phimosis will not account for the inability to empty the bladder, impacted 
calculus should be suspected. The secondary effects of calculus are cystitis, 
pyelitis, and suppurative nephritis. The ureters may become dilated and 
inflamed by extension of mischief from the bladder : and obstruction to the 
outflow of urine, suppurative pyelitis, and subsequent extension of suppura- 
tion along the renal tubes and in the peritubular tissue may result. This is 
probably not always fatal, and on removal of the stone the kidney mischief 
may subside : nevertheless the injury so done to the kidneys may be one of 
the reasons why children, the subjects of stone, seldom seem to grow up, 
though the mortality from lithotomy is so small in childhood ; it is, as 
Mr. Erichsen says, very rare to see an adult who has been cut for stone in 
childhood. 

Diagnosis. — One or more of the symptoms of stone may be caused by 
many other conditions : worms, phimosis, a contracted meatus urinarius, 
simple or tubercular cystitis,, the so-called irritable bladder, 1 vesical tumours, 
and renal calculus, all may simulate stone in the bladder to a certain extent ; 
the diagnosis is only to be certainly made by sounding. Stones can often 
be felt by bimanual palpation, one finger being passed into the rectum and 
the other hand pressed down above the pubes. 

Treatment.— Until recent times lateral lithotomy has been practically 
always the mode adopted for removal of a vesical calculus in boys, and its 
success is so great that but little attempt has until lately been made to find 
any other treatment. Median lithotomy is little applicable, on account of 
the small size of the parts. Of late the operations of litholapaxy and supra- 
pubic lithotomy have both been employed in children. Keegan, in the 
'Indian Medical Gazette,' May 1884 (vide also 'Lancet,' vol. ii. r 886 and 
1890),'-' has collected over one hundred cases oflithotrity in children between 

1 Thus, for instance, hematuria may result from phimosis and consequent In 
bladder (Bryant), and also may be due to tubercular cystitis. See also p. ^; t . 
- Also Southam, Med. Chron. vol. xii. 1800. 

00 a 



564 Diseases of the Genito-urinary System 

the ages of one and a half and eleven years ; among these there were three 
deaths ; in six cases the stone was allowed to escape with the urine after 
crushing, in the rest it was evacuated ; the size of the calculi varied from five 
grains to four drams. 

It is now well established, chiefly by the work of Keegan and Freyer in 
India, that the urethra of a child of three or four years will readily admit a 
No. 8 lithotrite after slitting the meatus, and we have found no difficulty 
whatever, as far as this goes, in the cases in which we have tried it ; such 
an instrument is abundantly powerful for the vast majority of stones Ave 
find in children, and there seems no valid reason against lithotrity on this 
ground. In one of our cases, however, the lithotrite broke in the child's 
bladder, and was removed, together with the stone, by suprapubic lithotomy. 
This child died of bronchitis shortly after. The death was clearly the result 
of the somewhat prolonged operation and exposure. Freyer even says that 
a No. 6 canula may be readily passed in a child under one year old, though 
this is not always the case. In our own cases there was some difficulty in 
seizing the stone, but this was got over in one case by passing a finger into 
the rectum and lifting the stone between the blades of the lithotrite. The 
operation, in this instance, was followed by pyaemia, and the child died ; 
after pyaemia had developed it was found that a second stone existed, and 
this, being lodged in the neck of the bladder, was removed by median litho- 
tomy, but the pyaemia was in no way improved. We do not, however, look 
upon this case as any argument against lithotrity, though it must be remem- 
bered that the natives of India bear surgical operations far better than 
Europeans, provided no bone lesion is present. In our case kidneys and 
ureters were both diseased, and probably this condition largely contributed 
to the fatal result. Though the cases we have mentioned show that litho- 
trity in children is not without its difficulties and dangers, we have no doubt 
from our own experience that it is the proper operation to perform in cases 
where the stone is small or of moderate size, and the child is not too weakly 
to bear an often necessarily prolonged manipulation. In any case a well- 
fenestrated lithotrite is essential, as detritus is apt to become jammed in 
the blades, and thus to prevent the withdrawal of the instrument without 
difficulty. We have had to open the urethra and protrude and clear the 
lithotrite before it could be withdrawn through the front part of the passage. 

As to the suprapubic operation, there is much to be said both for and 
against it. Against it is the risk of wounding the peritoneum, the risk of 
urinary infiltration, and the fact of the good results following the lateral 
operation. In favour of it is the fact that the operation is done as it were in 
the open : there is no cutting in the dark, no risk of wounding important 
structures such as the rectum, pelvic fascia, and seminal ducts, 1 while injury 
to the peritoneum is only likely to occur exceptionally, and is less likely 
in children than in adults, from the fact that in children the bladder is an 
abdominal, in adults a pelvic organ. 

Suprapubic lithotomy in children has, as shown by Sir \Vm, MacCormac 
and others, a very small mortality ; it is an easy operation, and requires no 

1 Sir Wm. MacCormac quotes Haemstadt, to the effect that of eighteen males who had 
been lithotomised in childhood, and had grown up and married, only one had children. — 
Lancet, March 19, 1887. 



Stone in the Bladder 565 

skilled assistance. In performing the operation no rectal bag should be 
used ; the bladder should be injected with from 3 to 4 oz. of boracic lotion 
and a gradual dissection made down to the organ, not using the knife after 
the peri-vesical fat is exposed. A staff should be kept in the bladder during 
the operation, and its end used as a guide upon which to open the bladder ; 
by pushing the bladder up gently with the staff, and opening the viscus lower 
down, all risk of injury to the peritoneum is entirely avoided. As soon as 
the bladder is laid bare, two sutures are passed through it, and the organ is 
opened between them, the stone is extracted with forceps or the finger, and 
the wound either left altogether open, or the bladder stitched up, the super- 
ficial structures being left quite open. Any stitches passed through the 
bladder walls should not include the mucous membrane. It is well to keep 
the child on its side or face after the operation, to allow free drainage away 
of any urine that may collect in the wound. In several cases (R. W. Parker 
and others) the wound has united by first intention, but, on the whole, we 
think it better to leave the rest of the wound open while the bladder wound 
is sutured, or perhaps better still to use no sutures at all. The operation 
has largely replaced lateral lithotomy, but further experience is required. 
We have not done lateral lithotomy for several years, all cases of stone 
having been dealt with either by lithotrity or the suprapubic operation. 

It is unnecessary here to describe the operation of lateral lithotomy ; it 
will be sufficient to point out that the operation in children differs from that 
in adults chiefly in that in childhood the field of operation is smaller, not 
only on account of the size of the patient, but because the genital organs are 
undeveloped and the prostate exists only in a very rudimentary condition. 
It is usually said that in children the difficulty of the operation is in getting 
into the bladder, in adults it is in getting the stone out. This arises partly 
from the small size of the parts already mentioned, partly from the fact that 
the bladder in children is more an abdominal than a pelvic organ, and partly 
because the tissues of the child are more easily lacerated than those of the 
adult, and very gentle manipulation is therefore required. In lateral lithotomy 
in a child the incision is usually carried through the whole depth of the pro- 
state, instead of only through a part of the gland, and unless the opening 
into the bladder is fairly free there is a risk of pushing the bladder before 
the finger and stripping it up from its attachments, or even of tearing across 
the urethra. The only other point requiring remark is that in children it is 
often easy by passing a finger into the rectum to bring the stone within the 
grasp of the forceps, or even to extrude it from the perinaeal opening, and 
this is still further facilitated in some instances by pressure with the hand on 
the abdomen. In one case we could easily grasp the stones (there were two] 
with the hand through the soft, flaccid, abdominal walls. 

Vesical calculus is occasionally found in female children : in such cases 
the urethra should be rapidly dilated with a three-bladed dilator or a pair 
of dressing forceps, and the stone extracted. If the calculus is large, it 
should be crushed before extraction and the bladder well washed out. Rapid 
dilatation is not, as a rule, followed by incontinence, even temporarily ; in a 
case of our own the urethra of a child three years old was dilated sufficiently 
to admit the little finger, and there was no incontinence, even immediately 
after the operation. 



566 Diseases of the Genito-urinary System 

The mortality after lithotomy in children is usually about 5 per cent. 
Death when it occurs is clue either to exhaustion of the child by distress and 
pain before the operation, to kidney disease, or in some cases to peritonitis, 
cellulitis, septicaemia, or haemorrhage. 

Cystitis. — Though cystitis in children is very commonly due to stone, it 
is by no means rare to find other causes for it ; thus retention from phimosis 
or a contracted meatus, or possibly a growth, may give rise to it : tuber- 
culosis of the bladder often is a cause of severe cystitis with much pain and 
haematuria, while frequent micturition with phosphatic deposit often occurs 
in children from such causes as errors of diet, or from no obvious reason. 
Rectal irritation may give rise to frequent micturition and even to 
haematuria. 

The so-called ' irritable rugous bladder ' is a condition often described as 
a disease ; there is no doubt that certain children are brought with symptoms 
pointing to stone, and on sounding them no stone is found, but the bladder 
feels rough and traversed by ridges. We are, however, inclined to think 
this is not a pathological condition in itself, but simply the result of some 
passing irritation such as hyperacid or phosphatic urine, since these cases 
seldom require prolonged treatment and usually rapidly lose their symptoms 
after a course of salines followed by tonics. In Mr. Holmes' view it is simply 
a contracted bladder resulting from some irritation. Renal calculus and 
phimosis sometimes are the cause of this condition. 

Tumours of the bladder are rare in children ; one case of prostatic turn out- 
has been already mentioned, and Owen records a case of his own, and 
mentions Giraldes' and Birkett's cases. Shattock has also recorded a case 
of mucous polypus in the 'British Medical Journal,' 1883, page 15, and 
several cases of sarcoma have also been met with {vide Southam) ; indeed 
sarcoma of the bladder occurs more frequently in childhood than any other 
form of growth. 

Tubercular cystitis may be recognised, in the absence of stone or other 
obvious cause, by pain in urination, itching at the end of the penis, pain in 
the hypogastrium and perinaeum, frequent micturition, and sometimes incon- 
tinence. The pain may be greatly lessened by passing urine as soon as the 
least inclination to do so is felt ; the urine is alkaline, with a deposit of pus 
and stringy mucus and epithelium; sometimes there is haematuria, and the 
bladder usually very readily bleeds — for instance, after gentle sounding. We 
have found a chain of enlarged lymphatics on rectal examination in a case 
of this sort, and also swelling, probably glandular, in the iliac fossa. Pres- 
sure over the bladder sometimes relieves pain. We have not found tuber- 
cular cystitis in children associated with genito-urinary tuberculosis, as is so 
commonly the case in adults, but the disease is not common enough to speak 
with authority. Terrillon says the deposit is less gelatinous and more floc- 
culent, and the pain more constant in tubercular than in simple cystitis, 
while bleeding is an early symptom. Where the bladder alone is involved no 
casts will be found in the urine ; their presence would of course point to 
renal mischief. Ulceration takes place after a time, and the ulcers may be 
single and small, or numerous and large ; they are usually at the trigone. 

Treatment. — Alkalies, citrate of potash, and boracic acid are the remedies 
most useful as given internally, opium and henbane being added where 



Incontinence of Urine 567 

much pain is present. Washing out the bladder with boracic acid (gr. x to 
5 i) is of much value in simple, but sometimes too painful in tubercular 
cystitis. Powdered iodoform washed into the bladder forms a coating upon 
its surface, and gives much relief in some cases ; it appears, however, to be 
somewhat specially prone to cause iodoform poisoning : this method was, 
Ave believe, first used by Mr. Whitehead for malignant disease. Rawdon 
suggests cystotomy in cases of tuberculosis where the symptoms are intract- 
able, and supra-pubic cystotomy with subsequent scraping of the ulcer has 
been done in some instances. 

Incontinence of Urine. — During the first few months of life the infant 
makes no attempt to retain urine in the bladder for more than a very short 
time ; after the first year, however, constant or very frequent micturition 
should lead to the suspicion of something abnormal. Unduly frequent 
micturition may be due to mere habit, to a too often recurring desire tD pass 
urine, or to an absolute inability to retain it. In the former the apparatus is 
perfect, but is by some cause or other too often excited ; in the last there is 
either paralysis or a malformation. Nocturnal incontinence belongs to the 
former group ; diurnal or continuous incontinence may be due to either con- 
dition. Thus a child may have a frequent desire to pass water because a 
larger amount is secreted, as in diabetes insipidus ; because it has a con- 
genially small bladder ; because it has a stone or hyperacid urine, or 
•cystitis, or a feeling of irritation about the penis from an adherent or tight 
prepuce or a contracted meatus ; or because worms or other rectal irritation 
are present. In all these conditions, except that of too small a bladder, the 
urinary apparatus may be quite perfect, but it is irritated. 

On the other hand there may be continuous dribbling of urine from the 
bladder, as a result of distension and overflow from obstruction ; or in case of 
entire absence of the bladder, or extroversion, or imperfect development of 
the neck of the bladder or of the urethral muscles ; or, again, from deficient 
innervation, as in paraplegia, or from imperfection of the micturition centre 
in the spinal cord, as seen in some cases of spina bifida. Mention must also 
be made of certain rare conditions, such as an abnormal communication 
between the bladder or ureters and the exterior. Obviously a child that can 
hold its water during the day can have none of these conditions ; hence, when 
a child is brought and said to be unable to hold its water, the first question 
is whether the condition is nocturnal only or constant. Dribbling from over- 
distension due to obstruction is nearly always the result of either an im- 
pacted urethral calculus or of phimosis, less often of a contracted meatus, 
though, of course, in these there is, as a rule, complete, or almost complete, 
retention rather than overflow. 

Inability to retain the urine is occasionally seen associated with hypo- 
spadias and incontinence of faeces : in such cases the condition is no doubt 
due to actual malformation of the sphincters. 

Dribbling from paraplegia will be recognised by the associated paral) ses : 
so too with the case of spina bifida : hence examination o\' the spine should 
be made in all cases, and the child's cerebral condition should also be 
inquired into. Failing these, careful examination as to the condition ot the 
bladder and urethra should be made, to see if there is any deficiency or 
abnormal arrangement of these parts. 



568 Diseases of the Genito-urinary System 

Diurnal incontinence is much less common than nocturnal, though fre- 
quent micturition without any actual inability to retain urine is common 
enough ; in such cases the sources of irritation already mentioned should 
be sought for and removed. Sometimes a child, the subject of nocturnal 
incontinence, passes urine frequently by day, but is able to retain it. 

Ordinary nocturnal incontinence (or enuresis, as it is sometimes called) 
is more common in boys than in girls ; it may occur at any age before 
puberty, but very rarely persists beyond that time ; if it does so it is usually 
incurable, and this rare condition is said to be most often met with in girls. 

The discharge of urine may take place once or several times during" the 
night ; perhaps most often during the first sound sleep, and again in the 
early morning. 

In cases of nocturnal incontinence those conditions which have been 
mentioned as giving rise to a frequent desire to pass urine during the day 
should be looked for, since, when the child is awake, he may be able to 
control the flow, or pass his urine in a suitable place ; while during sleep no 
such power is exerted. Other causes, such as unduly deep sleep, due in some 
cases to the semiasphyxiated condition caused by enlarged tonsils or post- 
nasal adenoids, dreams in which the child imagines that it is properly- 
passing its water, gastric disturbance from late or unwholesome meals,, 
temporary polyuria from free drinking of fluids at night, and perhaps mas- 
turbation, may be added to the list. We have also reason to think that mere 
delicacy of health, often conjoined with a somewhat unstable and easily 
excited mind, such as is sometimes seen in children born or brought up in 
hot climates, may give rise to enuresis. Possibly in some cases renal calculus 
or pyelitis of tubercular origin may give rise to incontinence. 

Treatment. — Setting aside the irremediable malformations and the cases 
due to paraplegia, the first thing is to look for and remove any of the sources 
of irritation. If there is phimosis, circumcision or the breaking down of 
adhesions ; if there is a small meatus, enlargement by incision will be re- 
quired. The bladder should, of course, also be sounded in any case of doubt,, 
or if the condition does not speedily yield to medicinal treatment. The 
urine should be carefully examined for over-acidity or for evidences of 
cystitis, and this should be corrected by the use of citrate of potash or liquor 
potassse ; the child should be carefully dieted and its allowance of meat 
curtailed, while any irritating vegetable food, such as rhubarb, should be 
forbidden. Late meals should not be allowed, nor should the child take any 
fluid for an hour or two before going to bed. Too great a weight of bed- 
clothes and the habit of sleeping upon the back should be avoided ; in the 
latter, the immediate contact of the urine, as it enters the bladder, with the 
trigone is believed to excite the effort to empty the viscus. 

For nocturnal incontinence alone the most successful drug is undoubtedly 
belladonna, or, still better in some cases, atropia. Belladonna should be 
given in full and increasing doses : for a child two years old it is well to 
begin with five or ten drops of tincture three times daily, and increase the dose 
by five drops every twelve hours till the physiological effects are produced, 
bearing in mind that children are not readily susceptible to the action of the 
drug ; as soon as this point is reached the dose should be continued for 
several days. If the treatment is successful it should be continued for a 



Retention of Urine 569 

week, and then the close gradually diminished, increasing it again if there 
is any relapse. We have seen liquor atropiai given at night in 2-minim 
doses, reached gradually, cure a child two years old in which belladonna 
had failed. The drug probably acts both by stimulating the contraction 
of the sphincter muscles and by acting as a sedative. Bromide of potassium, 
alone or with belladonna, ergot, cantharides, nitrate of potash, camphor, 
and other drugs, have been employed. Strychnine is chiefly of use in 
diurnal incontinence, though sometimes it succeeds in the nocturnal form ; 
it is said by Bouchut to be a dangerous drug for children. Such treatment 
as blistering, or painting over the orifice of the urethra with nitrate of silver, 
or the use of a perinatal truss, is not to be recommended. The child should 
be made to pass water just before going to bed, and should be taken up again 
in an hour's time, and if possible once again during the night ; he should be 
encouraged to try to control the inclination and to exert his will, but on 
no account should he be threatened or punished, except possibly in the 
exceptional cases when, as sometimes happens, the presence of one child 
with incontinence in a school induces an epidemic, as it were, among the 
others ; in such instances probably the affection is in the acquired cases 
simply a trick, and may be controlled by fear of punishment. The disastrous 
results of frightening such children into tying strings round the penis, as well 
as the misery inflicted by the shame of believing that what is really a disease 
is a fault, are sufficient arguments against such cruelty. Cold sponging to 
the perinaeum is sometimes useful, and we have known the use of the constant 
current, one pole being applied above the pubes and the other in the 
perinaeum or over the sacrum, to succeed where other means have failed ; 
the interrupted current also sometimes answers. The application of nitrate 
of silver to the neck of the bladder is advocated by Holmes. In weakly 
children and in cases of diurnal incontinence, when no organic cause can be 
found, tonics, iron, strychnine, good food, and sea air will often prove 
successful, and we have known sea air cure enuresis. The possible existence 
of chronic renal disease or diabetes. must be borne in mind. 

In inveterate cases in girls dilatation of the urethra and exploration of 
the bladder may, as pointed out by Owen, cure the affection even if no 
organic disease is found. 

Retention of Urine. — The causes leading to retention of urine are 
mentioned under their several headings, but it may be convenient here to 
group them together. They are congenital malformations, impacted calculus. 
phimosis, ruptured or strictured urethra, including stricture of the meatus, 
pressure on the urethra by abscess or a new growth, blocking of the orifice 
of the urethra by a vesical or prostatic tumour, or, lastly, the tying ot a string 
round the penis. It must be remembered that retention of urine may be 
voluntary, or imaginary on the part of the friends : voluntary where the 
passage of the water causes pain, as is often seen after circumcision, 
when the urine flowing over the surface causes discomfort. We have never 
seen any harm other than alarm to the friends result from this voluntary 
retention, though it is well in such cases, if a warm bath does not relieve 
the retention, to pass a catheter into the bladder. Lastlv. retention must 
not be confounded with suppression of mine from any cause. Of cou 
retention of urine if unrelieved will lead to extravasation, the treatment 



570 Diseases of the Genito-urinary System 

•of which is free incision deeply into all the infiltrated tissues, so that a free 
•outlet for the urine already extravasated is provided, as well as any further 
mischief prevented. 

Malformation of the Genito-urinary Organs. Extroversion of the 
Bladder. — Deficient closure of the ventral laminae, giving rise to hiatus of 
the abdominal wall, has already been mentioned in connection with umbilical 
liernia (p. 147). In certain, not rare, instances, however, the lower part of 
the abdominal wall, from the umbilicus or its neighbourhood downwards, 
may fail to close, and coupled with this there may be deficiency of the 
anterior wall of the bladder, constituting the condition known as extroversion 
or exstrophy of the bladder, ectopia vesicae, or hiatus of the bladder. A 
patent urachus or even a protrusion of the bladder wall through such a passage 
may also be found ; vide Tanner, ' Diseases of Childhood.' In this condition 
the lower part of the abdomen presents a red rugous area covered with 
mucous membrane, which is usually excoriated from friction and irritation, 
often more or less coated with mucus and phosphates. From this surface, 
or rather from the orifices of the ureters exposed upon it, the urine continu- 
ously dribbles, keeping the child always wet, and leading to irritation of the 
neighbouring skin. This red mucous surface is the posterior wall of the 
bladder, which is usually flush with the abdominal wall ; hence in most 
cases there is no bladder cavity, though occasionally there is a slight depres- 
sion. More often the surface is corrugated and somewhat protuberant, and 
on drawing down the penis, which is always distorted and ill developed {vide 
Epispadias), the orifices of the ureters can be seen, and drops of urine may 
be watched flowing from them, and often escaping in a little jet when the 
•child cries or strains. The malformation is most common in males. 

On further examining such a child, it will usually be found that the 
symphysis pubis is deficient, the two bones failing to meet in the middle line, 
and being only connected by fibrous tissue. The umbilicus may be absent 
altogether, or may be more or less well formed. The scrotum is always 
imperfectly developed, and the testes do not fully descend, usually lying in 
or just outside the inguinal canals. Very commonly there are inguinal 
herniae developed, and these may even become strangulated. We have had 
occasion to operate in such a case. 1 

1 According to Dr. Champneys, St. Bartholomew's Hospital Reports, 1877, extrover- 
sion may be associated with talipes and other deformities ; the sex may be doubtful from 
external appearances ; there may be rectal prolapse, with a long, loose, rectal mesentery. 
x\ll grades of deformities, from mere separation of the symphysis pubis, with perhaps a 
hernial pouch, but no deficiency of the bladder, may be met with ; in the second degree of 
deformity there may be prolapse of the bladder, though it is itself perfect ; the prolapse 
may take place through the urethra or urachus (Vrolik, Froriep) ; the third degree is the 
■ordinary form ; while in the fourth and most severe degree there is extroversion and divi- 
sion of the bladder into two halves by the opening of the intestine between them. The 
condition really arises from the fact that the allantois is developed by two lateral portions 
which afterwards meet in the middle line, and thus the various degrees of deformity of the 
bladder, epispadias &c. are explained {vide Baly in Miiller's Physiology). Union between 
the halves of the allantois takes place at the third week of fcetal life, so the deformity must 
exist at that time. 

The condition of the umbilical vessels is inconstant : they may run separately to the 
placenta (Dietrich). The umbilicus is lower than usual, and the anus is generally more 
anterior than usual. Hernia; are inconstant. The external genitals may be deficient 



Extroversion of Bladder 571 

This deformity, which is quite unmistakable, gives rise to much trouble, 
"both from the constant wetting and excoriations as well as from the in- 
capacities associated with it. It is impossible in most cases to fit any 
apparatus satisfactorily to receive the urine. Hence the treatment is solely 
operative ; and even this, it must be confessed, is not always satisfactory. 
Attempts have been made to divert the ureters into the intestine, but not 
hitherto with success (T. Smith and Simon). Holmes, Ayres, Wood, Greig 
Smith, and others have devised operations for covering in the exposed 
bladder ; these consist of dissecting up a flap from the abdominal wall or 
scrotum, and turning it over the bladder surface, subsequently covering over 
the raw side of the flap with other superimposed flaps from the groins. For 
details of the operation we must refer to works on operative surgery. Several 
successive attempts are often required before a good result is obtained, and 
there is sometimes a tendency for the flaps to retract and leave the lower 
part of the bladder exposed ; this difficulty is met by subsequent attachment 
of the flaps to the scrotum or labium below, a plan suggested by Mayo 
Robson, 1 and one we have found of value. On the whole, the result of our 
-experience is that the operation should certainly be done in all cases where 
the child is in a condition to bear a somewhat severe and prolonged manipu- 
lation, and that a great improvement may be expected as a final result (fig. 
114). The child should not be operated on until it is three or four years old. 
It has been proposed to scrape or cut away the mucous surface of the bladder 
•except at the orifices of the ureters, and thus avoid the irritation of the 
mucous secretion. We have not, however, tried this method. 2 After opera- 
tion one of the troubles is the constant formation of phosphatic deposit 
about the parts ; careful cleansing and daily syringing with a dilute acid 
solution is required. Hydrochloric acid, \\ xx, glycerine, 5 b water, 5 i, we 
have found a useful form of wash. If, however, as is sometimes the case, the 
deposit persists in spite of these measures, we have found that scraping it 
away from time to time with a sharp spoon is the most effectual means of 
getting rid of it. When the bladder surface has been covered in as shown 
in the figure, an appliance is readily adapted to receive the urine. 

In extroversion of the bladder in the male the penis is nearly always 

altogether or developed in varying degrees ; the testes may be retained, or may descend 
into the scrotum and be well developed. The symphysis is not always ununited ; when it 
is so it causes awkwardness of gait. 

As Tenon pointed out, the malformation is not a cleft of the bladder merely, since 
there is a deficiency of all excepting the trigone and neighbouring parts. The pelvis of 
the kidney and the ureters are usually dilated, and may open into the rectum, vagina, or 
urethra. 

The intestine is variously malformed or deficient, and there inav be imperforate or mis- 
placed rectum. 

For further details and references Or. Champneys' able paper should be looked at ; 
from it much of the above is taken. 

1 Brit. Med. Jour. January 31, t8 \. 

'-' Excision of the bladder, with or without transplantation of the ureters, direct suture 
of the vesical margins, with or without section of the sacro-iliac joints, to allow approxima- 
tion o( the: rami of the pubes, have also been sugested ; Inn no sufficiently encouraging 
results from these methods, except in one case o\ \\\ man's, have been obtained, V g 
summary of the various operations will be found in Ann. des Mai. des g 
nrinaires, March 1888, by Pousson. 



572 



Diseases of the Geni to -urinary System 



deformed, the corpora cavernosa are deficient to a greater or less degree, and 
the corpus spongiosum is ununited on its upper surface, so that the floor of the 
urethra is exposed on the dorsum of the penis. The whole organ is stunted 
and turned up against the abdomen ; the prepuce is usually redundant below, 
and the glans is generally better developed than the rest of the penis. 

Epispadias. — The condition of penis above described may occur without 
extroversion, constituting epispadias. 1 In such cases there is usually imper- 




Fig. 114. — Shows the result of a plastic operation for Extroversion of the Bladder ina boy. 
A urinal can be worn over the orifice now remaining, a points to the glans penis. 



feet pow r er of retention of urine from deficient muscular development at the 
neck of the bladder, and for sexual functions the organ is useless. In such 
cases an apparatus is readily applied to prevent the discomfort of constant 
wetting ; but to improve the power of urination, and perhaps the sexual 
function, operations may be performed, consisting in either turning down a 
hood-like flap from the front of the abdominal wall over the urethral groove, 

1 A case of epispadias in a girl is recorded by Smith in Brit. Med. /our. September 20, 



Hypospadias 573 

or in dissecting up flaps of skin and bringing them over the dorsum— or, 
lastly, in taking a flap from the scrotum and turning it upwards over the 
penis, which is passed through a slit in the centre of the flap. Any small 
fistulous openings left after union of the main flaps are closed by subsequent 
operation or by repeated application of the actual cautery. In all such 
operations it is a good plan, as a preliminary step, to open the urethra or 
bladder through the perinasum, so as to allow the urine to drain away freely, 
without flowing over the wound. Our colleague, Mr. Hardie, and Mr. 
Howlett, of Hull, have adopted this plan with good results. 

Hypospadias.— When the floor of the urethra, together with the corpus 
spongiosum, is deficient to a greater or less degree, the deformity known as 
hypospadias is present. In the slighter cases the deformity is merely one of 
the urethral orifice, which opens on the under surface of the glans penis 
instead of upon its apex, though, even in these cases, the corpus spongiosum 
is always thinner and less developed than it should be. A dimple usually 
represents the opening of the urethra, or a groove may run on from the 
existing opening to the end of the glans. All degrees of malformation are 
met with from this to cases where the urethra opens in the perinasum, behind 
the scrotum. In severe cases, the corpus spongiosum being entirely deficient 
below, the penis is bent downwards and held down by fibrous bands repre- 
senting the aborted spongy body ; it is also bound down by the deficiency of 
the prepuce below, though a redundant, hood-like fold overlies the glans above. 
In the severest cases the scrotum is cleft and ill developed, and the testes 
are retained or imperfectly descended, and the arrest of development may be 
such as to give rise to doubts as to the sex of the individual ; such are the 
majority of the so-called hermaphrodites. 1 

The slighter degrees of deformity, where the urethra opens at the base of 
the glans, need no treatment, and do not interfere with either the urinary or 
sexual functions as a rule, though we have met with a case where this 
condition was associated with incontinence of urine and faeces, probably 
due to deficient development of the sphincters of both outlets. In all cases 
of hypospadias a probe passed into the urethra will show how thin the 
lower wall is, and the meatus is often contracted and insufficient. Sometimes 
the opening is sufficiently far forwards to serve all purposes, but the penis is 
tightly bound down to the front of the scrotum. In such cases the organ 
may be liberated by careful dissection, but unless great caution is observed 
the thin floor of the urethra will be cut through, and a urinary fistula result. 
Where the opening is further back than half the length of the penis an 
operation may be performed to lengthen the channel ; a preliminary cysto- 
tomy or urethrotomy having been done, flaps should be dissected up from the 
sides of the penis and turned over one another { method o\ superimposed 
flaps). This is a successful plan, but even it often fails from non-union, or 
breaking down again after partial adhesions. We more often perforate the 
prepuce and bring U p the glans through it, and then, after refreshing the 
edges of the preputial fold and of the urethral furrow, unite them., completing 
the new floor of the urethra by subsequent operations. 

1 Sometimes the urethra is continued on to the glans, but there is .1 congenital u 
fistula further back, even within the rectum, and urine escapes b\ bol 

details o( the various forms o( hypospadias, .- /.;. .1, . December 1894, 



574 Diseases of the Genito-urinary System 

Congenital Contraction of the Meatus Urinarius and Congenital 
Stricture of the Urethra have already been mentioned. We have met with 
two instances of the latter : one, seen in adult life, was remedied by eatheterism 
in the ordinary way ; in the other, an infant, there was retention of urine, 
with overflow. On passing a catheter two distinct obstructions were found, one 
at the front of the scrotum, and the other in the prostatic region ; they appeared 
to be definite bars of thickened tissue, the latter closely simulating prostatic 
enlargement, which, if it existed, only affected the middle lobe. 1 

Congenital contraction of the meatus may become an important affection, 
giving rise to incontinence, to retention and consequent cystitis, and indeed 
to all the secondary troubles associated with obstruction to the urinary out- 
flow. In one instance a boy of five years old was brought to us, who was 
said to have had gonorrhoea for three years, and was believed to have been tam- 
pered with ; there was a distinct gleety discharge, and the meatus was very 
small. All the symptoms disappeared after slitting the meatus and passing a 
catheter a short distance down the urethra at frequent intervals for a few weeks ; 
the child was subsequently neglected, and re-contraction took place. The 
following case further illustrates the evils of a narrow meatus : 

Contracted Meatus Urinarius. Retention. — Jas. F. , age 4 years ; admitted December 7, 
1882. Well till five weeks before admission, when he was unable to pass urine without 
pain ; subsequently had pain in hypogastrium and became ill in himself ; never passed 
blood ; was catheterised at the out-patient room twice, and once passed urine voluntarily. 
On admission was found to have a contracted meatus, and was catheterised, a smalL 
instrument (size not recorded) being passed ; urine clear, sp. gr. IC28, faintly acid, slight 
sediment of mucus and phosphates on standing, no albumen ; the edges of the meatus 
were found to become glued together, and he was unable, even by violent straining, to pass 
urine himself; the bladder contracted tightly round the catheter. December n, the 
meatus was incised to enlarge the orifice, and a No. 8 silver catheter passed daily through 
the meatus, but not into the bladder. He was discharged on the 17th with all his symp- 
toms relieved. It is usually said that retention in children is always due either to impacted 
calculus or extreme phimosis. Here probably some balanitis led to ulceration and cica- 
tricial contraction of the meatus, the edges of which were probably acting as valves, which 
shut by the pressure of the urine. 

Complete obliteration of the urethra may also be met with, as in a case 
recorded by Partridge and Watson.- Mr. Gay and others have recorded cases 
of double urethra, one on the dorsum and the other in the normal position, 
both communicating with the bladder, though not with each other. 3 

Prolapse of the mucous membrane of the urethra in girls may be caused 
by straining ; it gives rise to pain, bleeding, and irritability of the bladder. 
Day, who describes the condition in the ' Medical Xe\vs, ; Dec. 1883, advises 
astringents in mild cases, and removal by ligature of the prolapsed part in more 
severe instances. Dr. Coley removed the prolapse by radial incisions and 
obtained a good result {vide ' Brit. Med. Jour/ November 1, 1890, also April 

1 Dr. Mudd, St. Louis Med. and Surg. Jour. November 1883, mentions a case of 
enlargement of the middle lobe in a child of thirteen months ; the swelling proved to be a 
myoma. 

2 Paih. Soc. Trans, vol. xiv. The ureters were enormously dilated ; one kidney was 
atrophied, and the colon ended in the bladder ; other deformities also existed. Another 
case, treated successfully by a sort of forced eatheterism, is recorded by Forster, of Darling- 
ton, Brit. Med. Jour. January, 3, 1885 ; also Shattcck, Lancet, February n, 1888. 

5 Path. Soc. Trans, vol. xiv. 



Phimosis 575 

12, 1890). Vascular growth of the meatus urinarius is occasionally met with 
in children (vide Eve, Lancet, November 1889). 

We have seen one case of complete absence of the penis, the urethra 
opening just at the margin of the anus, outside the external sphincter ; the 
scrotum and testes were well developed. The child was under the care of 
our colleague, Mr. Collier. For an account of other malformations of the 
penis, such as torsion, adhesion of the penis to the scrotum, double penis, 
penile fistula, &c, we must refer to Mr. Jacobson's work on ' Diseases of 
the Male Organs,' 1893. 

Phimosis, or the condition where a long prepuce exists which cannot 
without difficulty be drawn back over the glans on account either of the 
small size of its orifice or because of adhesions, is an affection which may 
be congenital or acquired. Further, it varies much in degree : the pre- 
puce may be very long and end in a puckered, tapering point, in which 
there is but a pinhole orifice. Tanner has found it absolutely imperforate. 
Where the opening is very small when urine is passed it collects between the 
glans and prepuce, and ' balloons ' out the latter, or the prepuce may be 
tightly stretched over the glans and universally adherent to it. 

In most children at birth the prepuce entirely covers the glans, and on 
withdrawing it adhesions are very often found between the two, while the 
coronal groove is filled up with retained smegma in round lumps ; if these 
adhesions are not broken down and the glans kept clean, secondary inflam- 
mation is apt to occur (balanitis) and give rise to still further adhesions, with 
perhaps increased contraction of the prepuce. In most cases, with a little- 
trouble, the foreskin can be drawn back, the adhesions being torn down by 
the finger and thumb or a probe ; the adhesions are frequently non-vascular, 
at other times a few drops of blood escape. Daily retraction and cleanliness 
for a week or two get rid of all further trouble, occasional drawing back 
and washing being all that is afterwards required. 

If phimosis is neglected, many ill results may follow : retention of urine 
from obstruction at the preputial outlet or at the meatus ; as a result of such 
contraction extravasation of urine may occur, or incontinence of urine from 
irritation. Prolapse of the rectum and hernia may result from the straining- 
required to empty the bladder or from irritation ; while cystitis, balanitis, 
formation of preputial calculi, masturbation, and in later life sterility and 
increased liability to venereal diseases and epithelioma may result from 
neglected phimosis. Other troubles, such as paraphimosis if a tight prepuce 
is drawn back, and, according to Mr. BarwelFs view, possibly joint lesions 
from reflex irritation, may occur. Sayre also records cases of various con- 
tractions and deformities of the lower limbs resulting from phimosis. 

If the obstacle to retraction is simply the adhesions, the breaking down 
of these, already mentioned, is sufficient ; if, however, the preputial orifice 
is tight, circumcision should be performed in infancy. Dilatation of the 
prepuce answers in some cases ; but we are strongly opposed to it, since we 
have seen not only rapid re-contraction but also much inflammation set up, 
necessitating circumcision and a long delay in healing : it is not a good plan 

In any doubtful case it is wiser to circumcise, as the operation is as harm- 
less as any operation can be if done properly. 

In every male infant the condition of the prepuce should be attended to- 



576 Diseases of the Genito -urinary System 

■during the first few weeks of life ; much subsequent trouble may be thereby 
avoided. 

There are many ways of circumcising, of which we will only describe the 
two we prefer. Slitting up the prepuce should never be done in children : it 
is much better to circumcise properly. 

The child should be anaesthetised and a tape tied round the root of the 
penis ; then, with a pair of dressing forceps, the prepuce should be seized 
just in front of the glans, but it is not to be drawn forwards so as to put it on 
the stretch, or too much skin will be removed. The forceps should be held 
vertically, and the skin in front of them shaved off with a scalpel ; but at the 
lower part of the section the knife should be turned forwards so as to make 
a little triangular tongue of skin projecting from the cut edge of the prepuce ; 
the dressing forceps are now removed and the skin retracts ; the mucous 
membrane is next slit up along the upper surface of the glans with a pair of 
scissors, and clipped away all round as far as the fraenum, leaving enough 
rim of mucous membrane to readily hold the sutures ; the fraenum should 
not be clipped close. Interrupted catgut sutures are used to stitch together 
skin and mucous membrane, generally one on the dorsum and one on each 
side are sufficient ; the little tongue flap is then stitched to the fraenum and 
made to cover in its raw surface ; by this means, which was shown us by 
Mr. Davies Colley of Guy's many years ago, rapid healing is usually obtained 
and there is no raw surface to granulate. The tape is removed and the 
patient kept lying down for a few days. We often slit up the prepuce with 
scissors, and then clip away the required amount of skin ; by this means it is 
easier to estimate exactly the length of foreskin to be left. It is better to 
do without any dressing, simply keeping the clothes away from the part by 
a cradle. If there is any troublesome oozing, a strip of lint may be wrapped 
round the penis, leaving the meatus exposed. Bleeding should be carefully 
arrested before putting in the sutures. Covering over the penis with a thick 
pad of cotton wool in a hollow of which a large mass of vaseline has been 
put is a good plan (Banks). 

In a perfect circumcision the edge of the prepuce will just cover the 
corona ; if too much is removed the corona is apt to remain tender and 
irritable for a long time. If catgut sutures are used they do not require 
removal. The Jewish mode of circumcision does not, we think, give such 
good results as that above described. Martin alleges that circumcision 
may produce contraction of the meatus, as a result of exposure and friction, 
.and various secondary reflex irritations, which he has relieved by slitting 
the meatus ; but we doubt the occurrence of any bad result from circum- 
cision properly performed, and think any such troubles are more likely the 
result of the condition for which circumcision is done. 

Balanitis is often met with in children, and is usually the result of ne- 
glected phimosis ; the prepuce may be much swollen, and large quantities 
of pus are sometimes discharged from within it; there is much scalding 
pain on micturition. Mild cases are readily cured by syringing out the cavity 
beneath the prepuce with warm water or lead lotion. As soon as the acute 
inflammation has subsided circumcision should be performed ; it is some- 
times necessary to circumcise at once, but in such cases the wound is apt to 
'be slow in healing. 



Paraphimosis — Masturbation 577 

The trick of tying a string or tape round the penis, for mischief, or to 
prevent the need of passing urine, is to be thought of in cases where a child 
is brought with swelling and inflammation of the penis ; the string may be 
completely buried in the soft parts, and may give rise to ulceration or even 
sloughing, urinary fistula, &c. 

Congenital Paraphimosis is the condition where the glans is congeni- 
tally uncovered by prepuce ; it is not a common condition, but is always 
found in hypospadias, even in the slighter degrees. 

Acquired paraphimosis is produced by retraction of a tight prepuce, so 
that the glans is exposed ; it is usually the result of mischievous meddling 
with the penis. If the prepuce is not speedily drawn forward again, the tight 
foreskin constricts the penis behind the corona and interferes with the venous 
circulation both in the prepuce and the glans : the result of this is swelling 
and pain, the swelling being chiefly of the prepuce, since its tissue is more 
lax than that of the glans. If the condition is neglected the appearance be- 
comes somewhat alarming ; there is much oedema, often redness, and some 
ulceration with distortion of the organ. Since the constriction is tightest on 
the dorsum of the penis, there is little or no risk of ulceration into the 
urethra, and still less of complete gangrene, as has been sometimes stated, 
but much trouble and no little alarm are often caused by this condition, and 
we have known it give rise to suspicions of erysipelas ; it might also possibly 
be mistaken for extravasation of urine or cellulitis. The treatment of the 
affection consists in drawing forward the prepuce again ; to do this the 
swollen foreskin should be punctured with a needle and all the serum squeezed 
out : by then drawing forward the prepuce with the fore and middle fino-ers 
of both hands, at the same time pressing back the glans with the thumbs 
reduction can be accomplished, unless the constriction is very tight or of lone 
standing. Another method consists in winding a piece of tape or narrow 
elastic round the penis, from the glans backwards, and so, by reducing the 
size of the glans, the foreskin can be brought over it. Where the paraphi- 
mosis has existed for more than a few days it may be irreducible ; or if the 
constriction is very tight, it maybe necessary to divide the contracted prepuce 
behind the corona, but this is rarely required. Under such circumstances 
the swelling is to be reduced by puncture and a lead lotion dressing applied; 
in time the parts will model down, and, though permanent paraphimosis 
usually results, no serious harm occurs. After reduction of a paraphimosis 
if the foreskin is long and tight, circumcision should be performed, or in any 
case measures taken to prevent a repetition of the retraction. 

Masturbation. — Masturbation in children is usually the result of a Ions 
prepuce, or retained secretion, or of some other source of irritation about 
the pelvic organs in either sex, such as worms, balanitis, vaginitis stone. 
&c. The treatment obviously in such cases is to remove the source ot 
irritation ; circumcision is in obstinate cases desirable, both as a means of 
removing irritation and as a deterrent, while in older children, who are 
able to understand the matter, and in whom the habit is a bad practice ami 
not the result of any obvious physical cause, judicious speaking, pointino out 
the uncleanness and the debasing effect of the act, is the best line of treat- 
ment. Coupled with these plans should be care in avoiding opportunities, 
and, if necessary, punishment should the vice be persisted in. In all cases 

P V 



578 Diseases of the Genito-urinary System 

onanism should be treated first as a disease, and only as a vice when it is 
clear that no cause for it exists. 

(Edema of the Scrotum in children is sometimes met with apart from 
any obvious inflammatory condition : it may be part of a general oedema due 
to cardiac or renal disease ; in other instances it is the result of intertrigo, 
such as is met with in fat and dirty children ; occasionally it occurs without 
obvious cause, and in such cases some source of obstruction to the lymphatic or 
venous circulation should be looked for. Erysipelas, or diffuse cellulitis of the 
scrotum, penis &c. is also occasionally seen. In all these conditions attention 
to the general health and the use of lead lotion are usually all that is required. 

Diseases of the External Genitals in Females. — The congenital mal- 
formations of the external genitals of female children, apart from so-called 
hermaphroditism, are rare, with the exception of the simple adhesion between 
the labia minora of the two sides, which, as Mr. Holmes has pointed out, if 
neglected, may produce retention of menses in later life, and probably forms 
the majority of the cases of so-called imperforate hymen. The treatment of 
adherent labia is very simple : the adhesions are broken down readily with 
a probe, and a little oiled lint kept between the labia for a few days, together 
with ordinary cleanliness, is all that is required. 

Hypertrophy of the labia or clitoris in children, though common among 
the natives of some hot climates, is very rare in this country. We have, 
however, occasionally seen it, though rarely to an extent that required treat- 
ment. In a young adult, however, we have had occasion to remove hyper- 
trophic labia, the condition having lasted some years, but whether it was 
congenital or not we cannot say. Nothing short of operation is likely to be 
of any service. We have recently seen a case in which the clitoris of a little 
child was much enlarged and caused irritation ; examination showed that 
there was adhesion of the prepuce of the clitoris to the glans, with retained 
smegma, just as in the case of phimosis in the male. 

Nsevus of the labia is seen every now and then, and is best treated by 
puncture with the actual cautery. 

Of acquired affections, simple "Vaginitis, or, as it more commonly is, 
vulvitis, is frequently met with ; it is usually caused by neglect and dirt, 
and often by the irritation of thread worms, but is sometimes the result of 
inoculation with the discharges from other cases of vulvitis, or from older 
people by the use of dirty sponges for washing, &C. 1 Very rarely indeed is 
it the result of attempted rape, and such charges are often brought against 
innocent persons simply because the mothers conclude that all discharges 
from the genital organs in children must be venereal : and it should be 
remembered that some children are led to invent stories or to confirm 
suggestions made by ignorant or dishonest mothers. 

This simple vulvitis is very contagious in many cases and readily spreads 
from one child to another ; hence isolation, perfect cleanliness, the removal 
of sources of irritation, and the free use of antiseptic lotions such as per- 
chloride of mercury or boracic acid should be employed. In some cases 
astringent lotions such as sulphate of zinc or alum are useful, and iodoform 
should be well dusted into the vulva. In one instance we found prominent 

1 Kroner and De Amicis have found gonococci in non-specific blennorrhcea in children. 
Rev. Mens, des Malad. de V Enfance, December 1884. 



Aphthous Vulvitis — Noma 579 

masses of granulations in the vagina in a case that had long resisted ordinary 
treatment ; in this case nitrate of silver proved the best application. 

The so-called aphthous vulvitis is a superficial ulceration occurring not 
rarely about the labia in ill-nourished, neglected, and unhealthy children, 
especially common as a sequel or complication of one of the exanthems. It 
occurs also in some cases of nephritis, and may simulate the severer disease, 
noma, from the presence of dried blood on the surface, giving the appear- 
ance of sloughing, as in the following case : 

Acute Nephritis. Ulceration of Labia. — Mabel C. , age 2 years. Admitted October 
27, 1885. Two months ago an eruption appeared on the face and head, which has lasted 
since ; for the past fortnight the labia have been swollen and sore, small spots appearing 
first ; has had epistaxis for the last few days ; is said not to have passed urine since the 
24th ; bowels open this morning, motion quite black. On admission, pale, pasty, bloated 
child ; labia both much swollen and superficially ulcerated ; no vaginal discharge ; some 
superficial ulceration around the right ear ; eczematous patches on the head, covered with 
blood-stained scabs. 28th, seems very feeble ; no urine passed until this morning, and 
then into the bed ; vulva as yesterday, some thread worms seen about it ; eyes puffy ; does 
not take food well ; found dead in bed at 9 p.m. The vulva was dressed with carbolic 
lotion and boracic lint, and carbonate of ammonia and bark, with strong beef tea and 
wine, given. Temperature, 28th, M. 98-2, E. 96 "6. 

Post-mortem. — Both lungs rather congested and cedematous ; no pneumonia ; heart 
normal; kidneys swollen ; weighed together 3 oz. , not very congested; in one, cortex 
finely granular (like scarlatinal nephritis) with red points ; the ulceration on the vulva and 
head was quite superficial ; there was no sloughing ; it extended all over vulva to the 
vaginal orifice, 

The treatment consists in cleanliness, free stimulation, and abundant 
nourishment, together with such measures as the disease with which it is 
associated demands. 

According to Savarin aphthous vulvitis occurs most commonly in children 
of from two to five years, and usually is a sequel of measles ; the patches 
begin as blisters and then ulcerate ; they may finally become gangrenous. 
There is some fever and the parts around are swollen, but there is very rarely 
lymphatic enlargement. The labia majora are most often affected, but the 
process may spread to the perinasum, groin, &c. The disease has a certain 
resemblance to diphtheria and syphilis, but is distinguished from the former 
by the imperfect membrane formation, and from both by the multiplicity of 
the ulcers, the absence of lymphatic enlargement, and the history. The 
prognosis is favourable unless gangrene occurs, and the best applications 
are boracic acid and iodoform. 1 Tubercular ulceration may be met with 
about the vulva as in other parts. 

Noma Pudendi. — Noma pudendi or noma vulvae is a gangrenous affec- 
tion of the external genitals, of precisely the same character as cancrum oris ; 
it runs a similar course, occurs under the same conditions, and requires the 
same treatment. It is quite as fatal as cancrum oris, if not more so : it 
is, however, much rarer ; main of the cases of so-called noma are merely 
aphthous vulvitis. We have very rarely seen well-marked cases. Morse 
has found an organism in noma that he regards as pathogenies 

Wart) and cystic growths are mentioned by Mr. Holmes and others as 

1 Vide Savarin, Rev. Hens, des I . . M.n 1884. 

'-' .!/<•>/. Record, Januan [885. 



580 Diseases of the Genito -urinary System 

having been met with about the vulva and vagina in children, and would 
require treatment on general principles. 

Haemorrhage from the vulva or vagina is occasionally met with in infants, 
but is of trivial importance and requires no treatment (Holmes) ; vide chapter 
on Diseases incidental to Birth. 

Irritable Mamma. — Irritable or painful mammas are not uncommon in 
girls of from ten to fifteen years. There is slight enlargement of the glands, 
which are tender ; the pain is variable : usually one breast is affected at a 
time and the other is attacked later. This condition is usually met with 
before menstruation has occurred, but is probably associated with the physio- 
logical growth of the organs. A similar condition is met with to a less 
marked degree in boys about puberty. Occasionally the condition is simply 
hysterical. Treatment seems to be of little use, but all the cases we have 
seen have got well. Belladonna and strapping locally, with tonics and arsenic 
internally, should be tried. 

In infants the breasts occasionally suppurate ; this is usually the result 
of rough handling on the part of superstitious nurses, 1 and may result in per- 
manently stunted or retracted nipples. 

Abnormalities in the Descent of the Testicles. — In the fully developed 
child the testes should be in the scrotum at birth, or rather shortly before 
birth ; ~ it is not, however, rare for their descent to be delayed for varying 
periods — they may even pass into the scrotum as late as the time of puberty. 
Most commonly descent takes place between the second and tenth years 
(Hunter, quoted by Jacobson) ; if the testicle does not come down by the 
end of the first year, Curling says it is usually accompanied by a hernia. In 
some instances the organs are permanently retained within the abdomen 
(cryptorchism) ; sometimes one testicle descends, the other being retained 
(monorchism). When the testes have not reached their proper situation 
they may be found in the abdomen, at the internal ring, in the inguinal 
canal, in the upper part of the scrotum, in the perinaeum, or even in the 
thigh ; 3 and instances of descent of the testes through the femoral canal 
are on record. Usually the glands are movable, and, though they may 
generally occupy one particular position, they may often be drawn down 
or pushed up beyond that spot, just as their situation alters according to 
the contraction or relaxation of the cremaster and dartos under ordinary 
circumstances. 

We still know so little of the descent of the testicles that the cause of 
failure of this process must at present remain somewhat obscure. Possibly 
failure in the action of the gubernaculum, possibly simply a lack of 
development ; certainly sometimes adhesions to surrounding parts, to the 
funicular process, the intestine, or the mesentery, prevent the descent. 
Premature closure of the funicular process, contraction of the inguinal rings, 
or a deficient development of the scrotum in some cases, perhaps accounts 
for the failure ; other less frequent causes, such as shortness of the vas 

1 The breasts are pulled at to ' break the nipple strings,' with the idea of preventing 
retraction of the nipples in later life. 

2 Camper found the testes in the scrotum at birth in sixty-three cases out of seventy. 

5 Displacement of the testis into the thigh has been accounted for by the fact that 
some fibres of the gubernaculum testis pass downwards into the upper part of the thigh. 



Undescended Testis 



;8i 



abdomen, fusion of the two testes, or an enlarged epididymis, are mentioned 
by Jacobson. 1 

The condition of the glands when they are in an abnormal position is a 
question of importance : they are often imperfectly developed. In other 
cases, however, they are in no way defective, and cryptorchism by no means 
necessarily implies sterility, 
while monorchism is, of 
course, functionally still less 
important. 

Apart from functional im- 
perfection, various evils may 
attend imperfectly descended 
testes. From their abnormal 
position and diminished mo- 
bility they are in many cases 
more exposed to injury, as, 
for instance, when they are 
lodged in the perinseum or in 
the canal. If a testis becomes 
inflamed from injury or other 
cause, the symptoms are 
likely to be much more serious 
if the gland is retained within 
the abdomen or in the canal, 
while retained testes are said 
to be frequently the seat of 
new growths.'- Most impor- 
tant, perhaps, of all is the 
effect of an imperfect descent 
of the testicle upon the forma- 
tion and persistence of hernia. 
By keeping the inguinal canal 
and rings open, the misplaced 
organ directly encourages 
the descent of a hernia. 
Where the gland acquires adhesions to the bowel and then descends into the 
canal, or even where the adhesions result from descent of a hernia after the 
testis, the matter is still further complicated, and great difficulty in the 
management of such cases may arise. 3 It is quite common for a child to be 
brought with the statement that it is ruptured, and that it has perhaps been 
weaving a truss -but this is said to have been always painful, and the child 

1 Diseases of the Male Organs of Generation, 1803; &«fc also Lockwood 
Jour. 1887. 

- Especially, according to Virchow, when they are retained in the ing lal; be 

points tun that obscure abdominal tumours, in the absence of any more ob\ ioug 1 
should induce examination for an undescended testis. 

The caecum may descend with the testis in consequence, possibly, of unusual stn 
angement of that portion of the mesorchium called the 




Fig. 



i.v — The right testis is undescended, and is seei 
forming a swelling in the inguinal canal. 



or abnorma 
(vide Lockv 



ood, Med. Chir. Trans, t886) 



582 Diseases of the Genito-nrinary System 

screams all the while it is on. Examination shows an undescended testis 
lying in the canal, which has been pressed upon by the truss, and. of course, 
the child could not bear it. In such cases the undescended testis is often 
the supposed hernia, though frequently enough the two conditions co-exist, 
and a reducible hernia is found to descend above the testicle. We have 
met with a case in which both testis and hernia were strangulated ; we 
removed the testis, closed the canal, and the patient made a good recovery. 

The late Mr. John Wood made some valuable remarks upon this subject in 
his lectures published in the ' British Medical Journal,' June 1885. Where a 
hernia and an imperfectly descended testis co-exist, the gland, if wasted, may 
be removed ; if adherent to the bowel it may be returned within the abdomen, 
and the ring closed, or, if possible, may be separated, drawn down into the 
scrotum, and fixed there, the sac and canal being closed above it. In 
funicular hernia a tunica vaginalis may be made by detaching part of the 
funicular process, and bringing it down into the scrotum ; if the cord cannot 
be drawn out enough to let the gland come down, the epididymis may be 
loosened from the testis, and the latter turned down so as to reach the scrotum. 
All Mr. Wood's results in these operations were good, with one exception. 
The diagnosis of undescended testis is not often a matter of difficulty : an 
examination of both sides of the scrotum will generally clear up the case. 
But we would suggest a word of caution not to be satisfied with too cursory 
an investigation : sometimes one testis may be down, and, unless both are 
felt for at the same time, may slip about so as to feel as if it belonged to 
either side ; sometimes, too, an empty scrotum may be felt, but a little exa- 
mination and manipulation of the canal, or the application of heat, may 
bring down the testicle, and the case may turn out to be merely one of 
retracted, not retained, testis. 

Occasionally a hernia, if it contains thickened omentum or glands, may 
be taken for a testicle or a hydrocele of the cord, or a fibrous or fatty tumour 
may simulate a testis in the canal. There is considerable variation in the 
size and firmness of the testes of young children, and we have frequently 
seen mistakes made about these conditions. 

The treatment of undescended testicle is an important and sometimes 
difficult matter. Where in an infant or child three or four years old there is 
an undescended or imperfectly descended testicle, with no hernia, nothing 
should be done except gentle attempts to bring the gland further down by 
pressure from above with the fingers ; this manipulation should be repeated 
frequently during the day. In an older child, up to the age of puberty, the 
same line of treatment should be adopted as a rule ; if, however, the testicle 
gives rise to pain or trouble, an attempt may be made by operation to bring 
it down and fix it to the bottom of the scrotum. Mr. Wood had some 
successes, as already stated ; we have performed the operation in a good 
many cases, but though it is sometimes successful we have found that there 
is often a great tendency for the testes to again become retracted. The 
scrotum in such cases is often small and ill developed. The operation 
consists in exposing the testis as in an operation for hernia, and passing a 
silk or catgut stitch through its outer tunic, or between the gland and the 
epididymis, and then bringing the suture out at the bottom of the scrotum 
and fixing it there. Testis in perinseo is probably best treated by replacing 



Displaced Testis-- Supernumerary Testicles 5 S3 

it in the scrotum— by operation, if possible ; if not, and its presence gives 
rise to trouble, it should be removed. Mr. Jacobson advises that all such 
operations should be postponed till after the first or second year. It is 
essential to freely separate the testis from all the adhesions which usually 
exist, so that it lies quite readily in its new position, even before it is 
stitched there. The adhesions may be remains of that part of the guber- 
naculum which is attached to the tuberosity of the ischium, and this may 
explain the abnormal position of the testis. 1 Displacement of the testicle 
into the perinaeum is sometimes the result of dislocation, and is not con- 
genital : under such circumstances it has been successfully replaced. - 

We must strongly protest against the use of a truss for undescended 
testis in young children with a view of keeping it out of the way, or preventing 
the descent of a hernia where no rupture already exists ; we cannot but con- 
sider the plan unnecessary and unscientific except in the cases where the 
testicle is inseparably adherent to the bowel, and, as this can only be ascer- 
tained by operation, we think it is wiser to operate in doubtful cases, separate 
the testis, bring it down, and close the canal above it if possible. If this cannot 
be done, the testicle should either be removed — which should be only done, 
as a rule, when the testicle is small and wasted, and can be separated from 
the gut without risk of injury to the bowel — or, after reducing it into the 
abdomen, the canal should be closed ; hence it is only in such cases that 
any obstacle to the descent of the testicle should be interposed. 

Should an undescended testis become inflamed from injury, from torsion 
or from pressure while in the canal, the symptoms may be severe, and may 
simulate those of strangulated hernia — the absence of the gland from the 
scrotum usually clearing up the doubt ; if, however, there is any uncertainty 
about it, or the symptoms do not speedily subside, the parts should be ex- 
plored, and the inflamed or gangrenous testis is generally better removed. 
Fatal peritonitis has resulted from this condition. 

Jacobson, in his well-known article in Holmes' 'System of Surgery' and 
book on 'Diseases of the Male Organs,' advises the use of Dover's powder, 
hydrarg. c. creta, and hot poppy fomentations in these cases in the early 
stage ; to this work we must refer for further details on this subject : to it 
we are indebted for many of the points in the present chapter. 

Where a hernia coexists with an undescended testis, but the two are not 
adherent, the best treatment is to apply a truss of special size and shape for 
the particular case, made so as to fit between the testis and the canal, and so. 
while the rupture is kept up, the testis is pressed downwards. We have em- 
ployed this plan usefully, and by its means both defects may be cured. 
Should the truss fail to procure closure of the canal, the hernia should be 
dealt with by the operation described in p. 150 ; the funicular process being 
closed above the gland, the descent of the testis will be favoured, and an 
attempt may be made at the same time to fix it in the scrotum. 

Supernumerary tssticles hardly ever occur. Most o( the supposed in- 
stances have turned out to be either hydroceles of the cord, herniae, or solid 
tumours. Lane has, however, recorded a recent case. Congenital absence 

1 Vide Lockwood, Hed. Chir. Trans., t886. 

3 Victor Horsley, Med. Times am December 1883. 



584 Diseases of the Genito -urinary System 

of the testes as distinguished from mere cryptorchism is an exceedingly rare 
condition and usually associated with other malformations. 

Deficiency or closure of the vas deferens is occasionally met with : in 
such cases the testis is well developed, but, of course, functionless. Inverted 
testicle, where the epididymis lies in front of the gland, is sometimes a con- 
genital, sometimes an acquired condition ; it may be of importance in case of 
the appearance of a hydrocele or hernia, or as a predisposing cause of torsion 
of the testicle. 

Mr. Tacobson's table of the complications of misplaced testis, in so far as it relates to 
children, is here summarised : 

1. The testis may be retained fa) in the abdomen, (7>) in the iliac fossa, (c) in the 
inguinal canal, (d) just outside the external ring. 

2. The testis may take an abnormal course into [a) the perinaeum, (&) the crural 
canal. 

3. Retained 'testis may become inflamed or gangrenous, may give rise to peritonitis, 
may simulate a strangulated hernia, or may become the seat of tubercular disease, of 
malignant growth, or may atrophy. 

4. Misplaced testis may be complicated with hernia, {a) from adhesion of intestine to 
the undescended testicle, or (b) from cc-existing patency of the funicular process. 

5. Hydrocele may be a complication, as (a) an acute condition from inflammatory 
effusion into some unobliterated portion of the processus vaginalis, or (&) as a chronic 
effusion ; in either case there may be a communication with the cavity of the peritoneum 
above, or extension into the scrotum below. 



Congenital displacement or Hernia of the ovary sometimes occurs, 
one or both organs protruding into the inguinal or even into the femoral 
canals, and occasionally in later childhood a similar malposition occurs. We 
have seen both ovaries prolapsed into the inguinal canals in a case of tuber- 
cular ascites, the ovaries returning to the abdomen on the subsidence of the 
fluid. If irreducible, the ovaries may give rise to trouble in later life from 
their enlargement at the menstrual periods, as well as from their presence 
keeping the inguinal canals patent : hence, where possible, they should be re- 
turned to the abdomen and kept back by a truss ; occasionally an operation 
as for hernia is required. 

Diseases of the Testicle in Childhood. — Simple acute orchitis in 
children occurs as a result of injury— undue pressure of a truss— or the result 
of an operation such as that for the radical cure of hernia or lithotomy ; some- 
times without assignable cause, or under circumstances mentioned in the 
case of hydrocele. The inflammation often results in the development of 
hydrocele, and there is often cedema of the scrotum ; but the affection is 
seldom severe, and subsides readily under the use of lead lotion, rest, and 
elevation. We have never seen any immediate bad result, though it is 
possible that the subsequent growth of the gland may be interfered with. 
Orchitis from mumps is very rare in childhood ; we have never seen it. 
Acute inflammation of the testis going on to gangrene may be a result of 
' torsion ' of the testis, an accident occasionally met with, usually occurring 
in cases in which there is some abnormality of the organ, and very apt to be 
mistaken either for an acute orchitis from some other cause, or for strangu- 
lated hernia, especially if, as is often the case, the testis has imperfectly 
descended. Chronic orchitis may result from the acute form. 



^^^MBi^M 



Tuberculous Testis — Tumours of the Testis 585 

Syphilitic Testitis is, in our experience, very rare ; Mr. Holmes mentions 
having seen hard knots in the testicle which were apparently gummatous ; 
they readily yield to the use of hydrarg. c. creta. Other cases have also been 
recorded, and sometimes a diffuse orchitis is found. We have met with 
cases of induration of the testes in young children for which we have been 
unable to account. 

Tubercular disease of the testicle is met with in two forms : as a part 
merely of a general tuberculosis, and as a localised condition limited to the 
testis alone or the gen'ito-urinary tract. Genito-urinary tuberculosis is much 
rarer in children than in adults, but it is common to find both testes tuberculous. 
In the former case the tubercles may be only miliary and disseminated, and 
hence not recognisable during life, or they may form definite, hard, circum- 
scribed masses in the epididymis, just as in adults. While the disease is 
limited to the testicle, it takes the form just described, giving often a sensa- 
tion as of a ' dumb-bell ' or double testicle ; it is usually not painful, and often 
of slow growth. If nothing cuts short the child's life, the testicle usually at 
last breaks down, and a suppurating ' strumous testis ' develops, with its 
characteristic adherent or undermined skin, livid colour, and intractable 
course ; the cord is usually thickened. 

Where the tubercle is generalised, no treatment of the testicular affection 
is, of course, of any use ; when, however, no obvious lesion exists elsewhere, 
the usual management, medicinal and dietary, of these cases should be 
carried out (cod liver oil, phosphate of iron, &c). For the testicle itself, 
pressure, with occasional inunction of mercurial or iodide of lead ointment, 
may be used, but as soon as suppuration occurs it is probably better to 
remove the gland ; it is in such cases most likely functionally destroyed from 
blockage of the efferent ducts, and is a source of general infection. The 
operation is sometimes advised as a precautionary measure as soon as a 
diagnosis can be made, but the propriety of this we think open to doubt : we 
have had occasion to perform the operation only once or twice, and in one 
case the child was seen two or three years later in good health, his brother 
being affected by 'general surgical tuberculosis.' In this instance the 
disease began at 7' weeks old, and the gland was removed at 18 months ; both 
testicle and epididymis were involved. Our colleague, Professor Dreschfeld.- 
has recorded a case of congenital tuberculosis of the testis in which tubercle 
bacilli were found. 1 Hernia testis occurs only in those cases where the 
body of the testis is involved, and when present castration is probably the 
wisest course. Occasionally the tubercular deposit gives rise to acute 
inflammation. 

Tumours of the Testis. — Tumours of the testis in children may be 
congenital or acquired ; the congenital are rare and usually teratomata or 
' dermoid,' consisting of cysts which contain hair, teeth &c. as in the corre- 
sponding tumours of the ovary. 2 Striped and unstriped myomata have, 
however, also been found,' 1 as well as congenital adeno- sarcomata, 1 and. 

' Brit, Med. Jour. iSo.|, p. 8 io. 

- Teratomatous tumours oi the testis are explained by Saint Hilaire as instances of 
'foetal inclusion;' by Owen as instances of parthenogenesis; and 
result o( • heterotopic plastique.' 

s Rindfleisch and Rokitansky. ' R. W. Parker, Pa S 885. 



586 



Diseases of the Genito -urinary System 



according to Silcock, 1 carcinoma — though Butlin disbelieves in the occur- 
rence of carcinoma testis in childhood. 

Acquired tumours are usually sarcomata (round-celled), very rapidly 
growing, very malignant, and tending to involve the lumbar glands very 
early. The large size, rate of growth, solidity, dilated veins, opacity, and 
bossy surface sometimes with cysts, make the diagnosis usually easy. These 
growths generally occur in the first few years of life, but according to Butlin 
are common from the time of birth to the tenth year. 

Xon-sarcomatous cystic disease may be met with ; the cysts usually 
arise as dilatations of the seminal tubules, and may be lined by cylindrical 
or ciliated epithelium. Immediate removal is the only treatment to be adopted 
in a case of malignant disease of the testis, though recurrence within a year is 
to be expected in most cases ; in simple cystic disease the same treatment is 
required, since a diagnosis between it and sarcoma is impossible. In the 
case of dermoid cysts it is sometimes possible to dissect away the cysts without 
injury to the testis. 2 

Hydrocele. — Hydrocele is a very common affection in childhood, most 
frequently met with in quite early infancy ; it may result from simple irrita- 




Congenital 
iorm. 



Congenital Encysted hydro- 
funicular form, cele of the cord. 



Common vaginal 
hydrocele. 

Fig. 1 1 6. — Diagram of the commoner forms of Hydrocele of the Vaginal Process. 
Altered from Lane. 



tion, intertrigo, &c, especially when, as is often the case in that condition, 
the testes hang loose and pendulous. It is sometimes caused by injury, the 
testis being squeezed by the child while keeping its legs crossed, or by other 
accidents. Hydrocele may be congenital where the whole processus vaginalis 
remains patent ; in this case if the communication with the peritoneal cavity 
remains free, the fluid will flow in and out according to the position of the 
child. We must say this condition is not often found : either the opening is 
a small one and readily occluded by flexion, or this form of hydrocele is rarer 
than is commonly supposed. 

Infantile hydrocele, so called, is the condition where the tunica vaginalis 
and funicular process are distended with fluid, the processus being closed at 
the internal ring ; this is a common condition. Again, the funicular part of 
the processus may remain open, but be shut off from the tunica vaginalis ; 
in such case a congenital funicular hydrocele would result. Or, finally, there 
may be an encysted hydrocele of the cord from distension of an unclosed 
segment of the funicular process. 

Diffused hydrocele of the cord, described as a sort of oedema of the cellular 



1 Path. Soc. Trans. 1885. 

2 Verneuil, Brit. Med. Jour. April 4, ii 
see Jacobson, op. cit. 



For a full account of testicular growths 



Hydrocele 587 

tissue of the cord, is believed to be very rare ; we met with a case while 
operating for hydrocele of the cord, in which there was some gelatinous 
material lying in the tissue of the cord, superficial to the funicular process, 
which contained ordinary clear fluid. Hydrocele (encysted) of the testis, 
and epididymis from dilatation of the hydatid of Morgagni, or organ of 
Giraldes, may possibly occur ; it is, however, usually a disease of later 
life, and no case appears to have been recorded in childhood. (Gosselin. , 

Diagnosis. — -The diagnosis of hydrocele in children is made by first 
examining the cord, and excluding the presence of a hernia by finding that 
there is no increased thickness of the cord above ; next, a soft, elastic, fluc- 
tuating feeling points to hydrocele ; and, finally, translucency, or the possibility 
of reduction gradually by pressure or elevation, without any gurgling sensa- 
tion, clears up the case. It is, however, certain that hernias in infants, when 
the bowel contains only flatus and is much distended, are sometimes quite 
translucent. Mr. Howse was, we believe, the first to point out this fact, 
and we have many times seen the same thing. 

When there is an encysted hydrocele of the cord it is usually possible 
to bring it clown by traction, and feel the absence of thickening above, or the 
tense swelling may be made to slip backwards and forwards between the 
fingers, quite unlike a hernia. The mode of reduction serves to distinguish 
a funicular hernia from a funicular hydrocele, and the absence of distinct im- 
pulse gives corroborative evidence. Hydrocele of a retained testis sometimes 
occurs and may give rise to difficulty ; the possibility of isolating it, its irre- 
ducibility, and its consistence, together with the absence of the testis from 
the scrotum, will give the clue. 

Combinations of two forms of hydrocele, e.g. of vaginal hydrocele with 
encysted hydrocele of the cord, may be met with, and a funicular process 
may contain fluid at one time and a hernia at another. Or there may be 
infantile hernia with infantile hydrocele. A collection of fluid may form in 
the sac of a congenital hernia, but is usually masked by the presence of bowel. 

Engel and Camper are quoted by Jacobson as having found the processus 
vaginalis closed at birth in about 10 per cent, only of children examined ; this 
supports the view that some abnormal condition of secretion in the abdo- 
minal cavity must exist to produce a congenital hydrocele, for it is certainly 
not as common as these figures would imply. 

Hydrocele in Girls — The funicular process in girls (canal of Xuck is 
occasionally the seat of hydrocele ; the diagnostic points and treatment are 
practically those of hydrocele of the cord in boys. 

Treatment. — Many cases of hydrocele get well without treatment : those 
due to local irritation subside on removal of the cause. The congenital form 
may disappear by spontaneous closure of the funicular process : other rases 
subside under the use of evaporating lotions, lead lotion, or mild counter- 
irritation such as painting with tincture of iodine. The congenital and funi- 
cular varieties are usually cured by a truss, and it is seldom that hydroceles 
give much trouble. When, however, these plans fail, the methods of treat- 
ment we prefer are : (1) injection with solution of pure carbolic acid in glyce- 
rine (1 part in 3) without emptying the sac of its thud, so that the injection 
is still further diluted ; (2) simple antiseptic incision : the sac is laid open and 
drained for tour or live days without any stitching of the edges o\ the sac to 



588 Diseases of the Genito-urinary System 

the skin, as in the so-called ' schnitt operation,' or part of the parietal layer 
of the tunica may be excised, and so the sac may be obliterated. Tapping, 
subcutaneous puncture, letting" the fluid escape into the loose scrotal tissue, 
setons, injection with iodine or spirit &c. all have their advocates, and are 
no doubt often successful ; but the plans mentioned are in our opinion the 
safest, 1 surest, and quickest, though relapses occasionally occur, whatever 
method is adopted. We have seen a hydrocele develop some time after an 
operation for the radical cure of hernia in an infant in whom the bowel was 
strangulated. 

CEdema of the scrotum is often met with as a result of intertrigo in 
children, and should be distinguished from hydrocele, anasarca, erysipelas, 
and extravasation of urine — also from the 'inflammatory'" or 'malignant 
oedema, : so called. 

Varicocele has been met with in childhood by Bryant, Pearce Gould, 
and Landouzy, but we have never seen a case earlier than about the tenth 
year, though we have seen a boy of thirteen with a large varicocele which 
was said to have existed for five years. 

Ovarian Tumours in children are nearly always sarcomata, teratomata, 
or dermoid cysts ; '-' they may appear at any age : thus Chiene 3 has operated 
successfully at three months, and Roemer 4 of Berlin at twenty months. The 
only treatment is abdominal section in the ordinary way. In the case of 
large tumours it may be impossible to make an accurate diagnosis between 
ovarian and renal or other congenital tumours until the abdomen is opened. 
Precocious puberty has in some instances been found associated with ovarian 
tumours. We have seen considerable development of the external genitals, 
with growth of hair and discharge of blood from the vagina, in a child 
three years old, who was the subject of a tumour which apparently involved 
the liver and the right kidney. Tuberculous pyosalpinx has once been met 
with by Chaffey, and once by Quarry Silcock/' 

1 Poland has recorded a case of fatal peritonitis after tapping a congenital hydrocele 
of the cord. — Lancet, December 1884. 

- Evers, St. Louis Courier of Medicine, August 1884, has met with a case of sarcoma 
in a girl of two and a half years. 

3 Edinburgh Med. Jour. June 1884. 

4 Jahrbuch f. Kindcrheilk. Bd. xxi. H. 4. Eight out of eleven cases collected by 
Roemer recovered. 

■' Path. Soc. Trans. 1885. See also Tumours of the Ovary Sfc. by Doran. 



58 9 



CHAPTER XXVI 

DISEASES OF THE BONES 

Diseases of the Bones. — A full description of the subject of inflammation 
in bone would be out of place in the present work, but a few of the more 
important points may be summarised thus : 

The process of inflammation as occurring in bone differs from that in the 
soft parts only in that the inflamed tissue is more rigid and unyielding ; hence, 
on the one hand, the progress of inflammation may be slower, and on the other, 
as tension is greater, its effects may be more destructive. 

As elsewhere, inflammation in bone leads to rarefaction, i.e. absorption of 
healthy tissue (rarefying ostitis), and this may go on slowly, and without any 
sufficient outpouring of material to develop pus or any obvious external 
signs of the changes going on. The bone slowly becomes thinner and 
weaker, and its tissue may entirely disappear ; such a change we see in 
the caries sicca, or non-suppurative caries, of the vertebrae or of the articular 
ends of the long bones. It is in some cases accompanied by a deposit of 
new periosteal bone while rarefaction is going on in the interior ; such a 
condition occurs in some instances of chronic osteomyelitis of the shaft of 
the femur after excision in hip disease. In these cases fractures may occur 
almost spontaneously, or at least from very slight violence. 

Again, in other instances, the inflammatory material may be in sufficient 
quantity, and so incapable of becoming organised that pus is formed, and this 
may infiltrate the adjacent bone, and so give rise to further extension of the 
process, without the formation of any definite abscess ; such a condition we 
see in some of the cases of chronic osteomyelitis of the long bones, epi- 
physitis, certain forms of necrosis of the jaw, &c. Under these circum- 
stances necrosis usually results, or if there is more abundant pus formation 
an abscess in bone is found. 

Where, in consequence perhaps (Cornil and Ranvier) of primary fatty 
degeneration of bone corpuscles, the bone tissue slowly dies, the dying part, 
acting as an irritant, gives rise to inflammation around, and the bone is slowly 
disintegrated, with more or less abundant formation of pus ; such a process 
is seen in ordinary caries of a rib or of the pelvis, or the articular etui 01 a 
bone. Where small islets of bone are marked out and, as it were, cut off from 
the rest by the surrounding inflammation, minute sequestra become de- 
tached (caries necrotica), while, if larger masses arc so separated by a 
of demarcation, common necrosis results. The last-named may, of course, 
be an acute or chronic process, a slow diminution in blood supply Ci us ng 
gradual starvation, or an immediate strangulation causing rapid gangrene 
o( the part (acute necrosis). 

So-called 'condensing ostitis' or 'sclerosis' is in its results an hyper. 



590 Diseases of the Bones 

making the bone denser and stronger ; the new material has sufficient vitality 
to stand, and sufficient blood supply to support it as well as the original tissue ; 
such a process we see in chronic periostitis, the results of which may be com- 
pared with the sclerosed bone of repaired rickets. 

Should, however, this deposit of new bone go on beyond a certain point, 
the blood channels become themselves so narrowed that the surrounding 
bone is starved, and so necrosis may result. 

It should be noticed that while some of these processes of destruction and 
growth and repair are constantly seen going on side by side, as where chronic 
osteomyelitis causes central necrosis and at the same time the periosteum 
forms a new peripheral layer of bone, in others we do not see any repair so 
long as the disease is spreading : thus, in caries of a flat bone or an articular sur- 
face, until the destructive process ceases, no new bone is, as a rule, laid down. 

Inflammation in bone may occur primarily either as a periostitis or as an 
osteomyelitis, the latter, often called osteitis, attacking the endosteum and 
marrow in the medullary cavity or in the cancellous tissue. Compact bone 
can hardly be supposed ever to be the seat of a primary lesion, though con 
stantly involved by direct extension along the Haversian canals from either 
periosteum or medulla, it being remembered that a thin layer of medullary 
tissue lies in each Haversian canal. Inflammation beginning in the epiphysial 
line may be considered as an osteomyelitis. 

Periostitis. — Acute periostitis, phlegmonous periostitis, or 'acute necrosis, 1 
is a disease essentially of childhood and youth, rare in infancy, 1 and, so far as 
Ave are aware, not occurring in adult life. The disease is seen in two distinct 
forms, corresponding to the anatomical structure of the periosteum ; in the one 
there is an acute inflammation, with pouring out of the inflammatory products 
between the surface of the bone and the deep fibrous layer of the periosteum 
(true, deep, sub-periosteal abscess) ; in the other the exudation takes place 
superficially to the deep fibrous layer, in the looser cellular zone which con- 
nects the periosteum with the surrounding cellular tissue (parosteal abscess). 
The difference in texture of these two layers is of the utmost importance, and 
is marked by striking differences in the course and results of the inflamma- 
tion. While the sub-periosteal effusion, whether serous or purulent, lifts up the 
periosteum from the bone, presses upon and detaches the vessels passing to the 
Haversian canals, and thus cuts off the blood supply to the affected part, and 
further, by the extreme tension under which it is pent in, gives rise to all those 
evil results due to pressure of confined fluid, on the other hand, the supra- 
periosteal exudation lies in loose tissue, interferes comparatively little with 
the blood supply to the bone, and is not bound down, so that there is but 
little tension. 

Either form of acute periostitis may be met with as a result of injury, 
exposure to cold and wet, as a sequel of one of the exanthems,' 2 or as a 
pyaemic condition. It will nearly always be found that one of these causes 

1 We have only twice seen it under two years old. Watson Cheyne mentions a case 
of Rosenbach's in which it occurred in utero, but this was considered to be an osteo- 
myelitis (? epiphysitis). — Brit. Med. Jour., March 3, 1888. 

2 Periostitis and necrosis after typhoid do not occur till the patient is well of his fever 
(Paget, Path. Soc. Trans. 1884). Macnamara, however, quotes Affleck's cases of peri- 
ostitis in the third week of typhoid. We have seen a case of acute periostitis of the fibula 
following exposure to cold after influenza. 



Acute Periostitis 591 

has produced, or at least preceded, the attack ; often two or more may be 
combined. The disease is no doubt an infective one. 

The onset of acute periostitis is marked by fever with its general constitu- 
tional disturbance, rigors, pain in the affected limb, with swelling coming 
on rapidly, and usually involving the whole length of the affected bone, and 
often the adjacent joints. Mr. Clinton Dent has pointed out that extension 
of suppuration to the joint is commoner is supra- than in sub-periosteal 
abscess; it certainly does, however, occur in both forms. The skin soon 
becomes swollen, red, and shining, and there is extreme tenderness. The 
temperature commonly, in the sub-periosteal variety, reaches io3°-io5°, and 
there is much prostration. Soon the swelling increases, and, if proper treat- 
ment is not adopted, in a few days pus finds its way to the surface and is 
discharged, with much relief to the symptoms. Usually, however, fresh foci 
of suppuration arise, and, if the child is neglected, in a large number of 
instances pyaemia occurs, and the patient dies ; in others, after much 
destruction of periosteum and the formation of many abscesses, the limb is 
left riddled with sinuses leading down to the bare dead shaft. 

Sometimes, but not commonly, the neighbouring joints suppurate by 
direct extension from periosteum to capsule, and thence to synovial mem- 
brane ; most often, however, there is merely a serous effusion, the result of 
interference with circulation, or a slight degree of inflammation. 

Suppuration of a joint by direct extension might be expected to be most 
common in the case of the hip, where the epiphysial line lies within the 
joint, and this complication does sometimes occur ; it is not, however, common 
in our experience. Of twenty-three cases of acute periostitis under our care, 
the femur was affected alone in eight instances, the tibia was attacked in six 
cases (in two of these there was extension upwards to the femur), the 
humerus alone in two cases, the humerus and ulna in one, the radius in one, 
the ulna alone in one, the fibula in one, a rib in one, the ilium in one, and 
a metatarsal bone in one instance was inflamed. Five of these cases were 
supra-periosteal (parosteal), and in them no necrosis followed. There were 
five deaths, all from pyaemia, and allin sub-periosteal cases; one child had 
non-purulent pericarditis (proved by aspiration) and recovered. 

Usually the inflammation is limited by the attachment of the periosteum 
to the epiphysial line, and does not reach beyond this ; sometimes it spreads 
in along this line and loosens the shaft from its epiphysis, or sets up an 
osteomyelitis. The same endosteal lesions may, of course, result from exten- 
sion inwards along the Haversian canals, but we think it is not the rule to 
find suppuration within the medulla, either epiphysial or diaphysial, as the 
result of acute periostitis. Quite apart from osteomyelitis, the whole shaft 
may necrose, probably because not only is the blood supply from the 
numerous small vessels entering the bone throughout its length cut ot\\ but 
also because the nutrient artery itself" as well as the supply from the epi- 
physial /one is lost. 1 

i\l r. Macnamara, M r. Tubby," and others believe that all these eases really 
begin as an inflammation of the epiphysial line, and that the mischief spreads 

1 Vide Dent's able paper, I t88i. Mr. Dent believes that the 

medulla may disintegrate without being inflamed at all. Vide also Makins an 
St. Thomas' s Hospital Reports^ 1881 - Brit. Med. . Ma> t t8Qi. 



59- Diseases of the Bones 

downwards and upwards, both beneath the periosteum and in the medulla. 
That such a condition does occur their specimens prove, and we readily admit 
from our own experience, but that it is by any means the universal condition 
we cannot agree. 

If left to itself, then, and the patient survives, acute periostitis results in 
necrosis of a part or the whole of the shaft of the long bone attacked ; sub- 
sequently new bone is thrown out by the sur- 
viving periosteum and surrounding tissues, and 
the sequestra are inclosed in the sheath of this 
new bone, in which are cloacae leading" down to 
the dead part. 1 

Probably because the disease is a somewhat 
uncommon one, it is often mistaken, when it does 
occur, for erysipelas or rheumatism ; most of the 
cases of necrosis resulting from it are said to 
have followed one or other of these diseases. 
From erysipelas it is distinguished by the much 
greater pain in periostitis, by the absence of 
any defined line of redness, by the limitation 
of the disease and its evident relation to the 
shaft of a long bone, and, as soon as an incision 
is made, by the exposure of the bone shaft. 

There is, of course, no real resemblance to 
rheumatism of joints, inasmuch as the joints are 
only involved in very minor degree, so that this 
is a less excusable mistake. The disease most 
closely resembling it, especially the supra-peri- 
osteal form, is diffuse cellulitis ; this, however, 
is usually more superficial and more widespread, 
not ceasing at the joints. In one case which 
we saw with Mr. Coates, of Manchester, the 
mischief spread from tibia to knee, and beyond 
this upwards to the lower end of the femur — 
but this is very exceptional ; there was no 
suppuration in the femur. We have had another 
very similar case, vide p. 591, note. 

There is but one treatment of acute periostitis 
at all worthy of consideration, and that is free 
incisions down to the bone through the periosteum, as soon as the disease 
is diagnosed : each incision should be about one inch to two inches in 
length, and made in the long axis of the bone, care being taken, where 
practicable, to make the incisions not all on one side of the limb, though, of 
course, important vessels &c. must be avoided. Several shorter incisions 
are better than one the whole length of the limb, as Mr. Holmes has 
pointed out. 

Bleeding is usually very free, and it may be necessary to plug the wounds 

1 Dr. Macewen, in a recent paper in the Annals of Surgery, expresses disbelief in the 
existence of anv bone-forming power in the periosteum, and believes that all new bone is 
formed from bone itself. His views are, however, not at present accepted. 




Fig. 1 17. — Acate Periostitis of the 
Femur, showing stripping off of 
periosteum and separation of the 
epiphysial junction. The lower 
part of the shaft has been re- 
moved post mortem. 



Acute Periostitis 593 

for a few hours, to arrest it ; the plugs should then be removed, drainage 
tubes inserted, and the wounds dressed every day or two, or oftener if there 
is much discharge. Should no pus be found at the time of incision, provided 
that it is certain that the bone has been laid bare, it may be taken as a 
proof that the disease is in its early stage, and the prospect is therefore 
better. In all cases, however, serum and flakes of lymph will be found, 
even if there is no pus, and there will usually be free suppuration in a short 
time. Too free exploration of the bone with the finger or probe, and too 
frequent or forcible syringing, are to be avoided, as tending to separate any 
still adhering periosteum, or to prevent adhesion after separation has oc- 
curred. The limb should be kept slightly raised, and stimulants, opium, 
and abundant nourishment given to the child. Should the fever not subside 
in a few hours, it is probable that some abscess has not been relieved, and a 
director should be passed round the bone, or a fresh incision made at any 
painful spot. In the tibia, for instance, where incisions can hardly be made 
at the back, pus may be lying beneath the periosteum at the back of the 
bone, bound down by muscular attachments. In spite of the authority by 
which it is supported (Billroth), we cannot regard applications of nitrate of 
silver or iodine, or anything except free incision, as good treatment. 

Since such extensive necrosis and so much suppuration with liability to 
pyaemia often follow in these cases, it has been proposed to resect the 
affected bone at the time of incision, and this has been done by various 
surgeons. Since the periosteum is preserved, a new bone is developed, and, 
it is said, without shortening in cases where a second bone exists, as in the leg 
and forearm. 1 We cannot say we see any great advantage in this method, 
and it is impossible in any case to be sure how much of the bare bone will 
die — usually it is only a very small portion compared with the part exposed ; 
and, though we have at a later stage removed nearly the whole of the shaft 
of some of the long bones as sequestra, it is common to see quite small 
portions of dead bone as the result of most extensive stripping off of peri- 
osteum. We believe that much harm is often done by the practice, already 
alluded to, of passing in the finger, sweeping it all over the bone, and then 
remarking that the whole bone is bare ; of course it is, for the operator has 
just stripped off the remaining periosteal attachments. We think, therefore, 
that primary resection of the diaphysis is not to be recommended unless it 
is absolutely detached at each epiphysial junction and bare of periosteum 
throughout— a very rare condition. Neighbouring joints should not be 
incised unless they are pretty clearly suppurating, i.e. a slight degree of 
effusion does not mean suppuration. If the joint is full of fluid, and the 
skin over it is hot and its veins turgid, or if the swelling does not subside 
rapidly after incision of the periosteum, the joint should be opened or, if in 
doubt, aspirated ; if pus is found, a free incision and the insertion o\ a 
drainage tube are required. 

It must be very rarely thai immediate amputation is demanded, even if 
joints are involved ; if there is no pyemia, a large proportion o\ the cases 
do well, and if pyaemia exists already amputation will not usually succeed. 

1 Much Shortening lias, however, followed in some cisos (vide Xcve. I 
Gae. April 188 |, who records a case of an inch and a half shortening after remova 
the upper half of the tibia ; also Holmes, Surg. Dis. of i 



594 Diseases of the Bones 

If after free incisions the symptoms do not subside, and especially if p\is 
escapes from the epiphysial line, there is probably suppurative osteo- 
myelitis ; the bone should then be exposed and trephined to give vent to the 
matter. 

The time at which sequestra may be expected to be loose after the onset 
of the disease varies with the size of the bone and the extent of destruction ; 
if the whole shaft dies the bone will probably be loose in a month or six 
weeks ; if only a part is necrosed it will vary from the time mentioned to 
many months, or, in the case of the femur, the bone, especially if the lower 
end is affected, may remain for years without being detached, and yet is so 
far devitalised that it acts as a foreign body and keeps up suppuration. This 
especially applies to periostitis attacking the popliteal surface of the femur, 
and holds good of chronic inflammation as well as acute. 

No absolute rule, then, can be laid down as to the time at which sequestra 
can be removed ; the sinuses should be explored with a probe from time to< 
time, and if the dead part can be felt to be movable it should be cut down 
upon and taken away. If no loose bone can be felt, but the probe passes, 
down through cloacae in the new bone to a sequestrum, the patient should 
be anaesthetised, the limb rendered bloodless, the sinuses laid open, the 
cloacae enlarged, and the sequestra examined : any that are loose should be 
taken away, and any distinctly dead but not loose bone may be cut away, 
but no doubtful bone should be disturbed — it may recover. The wounds are 
then plugged with iodoform gauze or lint, and daily dressed until they fill up 
or the sequestra become loose. It is very seldom that all the dead bone is 
removed at one operation ; usually small fragments either come away of 
themselves or have to be removed by later operations. In cleaning out the 
cavities in which sequestra lie great care should be taken not to break into 
joints or remove more new bone than is necessary. The delay in waiting 
for the separation of sequestra is not wasted time, for the new bone is mean- 
while consolidating and the limb getting stronger. In subsequent dressings- 
care must be taken to keep all the cavities well drained and syringed out, 
otherwise retention of discharges and detritus will give trouble. Unnecessary 
probing of sinuses is useless and harmful : it is useless to be constantly- 
feeling bone to see whether it is loose, for the process of separation is a 
slow one ; it is harmful, because broken granulations readily absorb septic- 
material, while sound ones are proof against it — moreover, it needlessly 
frightens a child. Where repair is very slow, and profuse discharge is 
wearing out the patient, it may be necessary to sacrifice doubtful bone for 
the sake of rapid healing, or even in extreme cases, chiefly where there is 
destruction of a neighbouring joint and great prostration, amputation may- 
be required. 

Case. — T. B., aged 6£ years, was admitted April 22, 1881. Three weeks previously - 
the boy fell down some steps and hurt his forehead and his shin, but seemed to get- 
quite well. Two days before admission he complained of pain in the left thigh, but ran 
about as usual. On the following morning he could not get up, had pain in the knee,, 
and could not move the leg ; he was delirious during the night, with profuse sweating.. 
On admission he was pale, dull, and heavy -looking ; respiration 48, temperature 106 , 
pulse 156, with low, muttering delirium. He was ordered four grains of quinine and 
brandy-and-egg mixture. The left thigh was swollen to nearly double its normal size 
from the top to the knee, and intensely painful. A short time after he came in, three free- 



Acute Periostitis 595 

incisions were made through the periosteum down to the bone ; much sanious sero-pus 
and lymph escaped. The bone was quite bare. After the operation the temperature was 
104 , falling to 102-4°. There was great prostration. The temperature again rose to 
106 "6° at 11 P.M., when he died. 

Post-mortem. — There were recent pysemic abscesses in the lungs, and the whole femur 
was bare from the neck to the lower epiphysis. No other disease was found. Vide fig. 117. 

Supra-periosteal abscess has the same general symptoms as the more 
serious conditions, but it is much less severe, for the reasons already men- 
tioned ; the pain and fever are less, though the swelling is often as great. 
On cutting into the abscess, and passing the finger in, the bone will be found 
still covered with the dense fibrous layer, and is consequently not bare. 
Necrosis seldom follows, or if it does it is limited both in extent and depth ; 
usually only a small scale of bone comes away. If this form of periostitis is, 
however, neglected, the deeper layer may slough, or the mischief spread 
through it, and more extensive necrosis may ensue. The diagnosis between 
the two conditions can generally be made by the less severity of the symptoms 
in the superficial variety. 

The immediate and later treatment is the same as that of the sub- 
periosteal form, i.e. free incisions at first, and subsequent removal of 
sequestra, should any necrosis occur. 

Case. — Supra-periosteal Abscess of Thigh. — -Mary Ann D. , age 13 years 2 months ; 
admitted December 24, 1882. Three weeks before admission she had pain about the 
lower part of the leg and walked lame ; the symptoms increased latterly, and the left 
thigh was noticed to be swollen and shining ; she had been getting thin and pale for two 
or three months previously ; no injury. On admission a large fluctuating swelling occu- 
pied the anterior and upper half of the left thigh, large veins ramified over the surface, 
there was a blush of redness over it, and some tenderness and pain ; an incision was made 
into the swelling, and a large quantity of pus escaped, which was in close contact with 
the bone, though the latter was doubtfully bare ; considerable bleeding took place into the 
abscess cavity, which stopped after a free counter-opening and more perfect drainage were 
employed ; she then "steadily improved, and was discharged weli on August 4. This 
case did not come under our care at first, and it was only at the second examination that 
we had an opportunity of exploring the bone ; at this time it was certainly not bare, a 
thin layer (deeper layer of periosteum) covering the bone. The constitutional disturbance, 
as usually occurs in the superficial periosteal abscess, was much less than in the sub- 
periosteal form, and no necrosis followed. 

A careful watch should be kept for the onset of pyaenra in all cases of 
acute periostitis ; it appears sometimes exceedingly rapidly. We have just 
mentioned a case of acute periostitis of the femur, which died with infarcts 
in the lungs and ecchymoses on the pleura: after an illness of altogether only 
two days, and another child died in the same way six days after an injury 
giving rise to periostitis of the fifth metatarsal bone. 

In some instances the periostitis is multiple at the first : these eases are 
no doubt pysemic, and sometimes occur after a primary joint lesion : thus we 
have seen acute suppuration in the ankle followed shortly by an abscess in 
the wrist, and a lew days later by periostitis of the humerus and ulna, and by 
pneumonia. After death no other lesions than these were found. In another 
case, of an infant six months old, periostitis o\ the tibia followed a suppurating 
nsevus of the scalp : the bone necrosed and gave way, a fracture resulting ; 
the child died of pyaemia, sinking, as they so often do. quite suddenly. 

Q l 



59$ Diseases of the Bones 

We have seen a case of pyaemic necrosis of the radius in which the lesion 
was close above the lower epiphysial line, but there was no shortening of the 
bone four or five years after. The patient was under the care of our friend 
Dr. Sellers, of Rochdale. 

The disease very rarely attacks any bones except the long bones of the 
limbs ; the tibia, femur, humerus, and ulna we have seen most commonly 
affected — sometimes the whole shaft, in other instances only a part, being 
laid bare. Occasionally the short and flat bones are attacked {vide T. Jones, 
' Diseases of Bones, : p. go). 

A case of acute periostitis of a vertebra is mentioned by Macnamara ; 
and vide note, p. 591. 

Case. — Necrosis of Fib [traumatic). Empyema. — Wm. G. , age 10 years 7 months ; 
admitted November 20, i83i. Nineteen days before admission fell with his side against 
the kerb-stone ; two days later had much pain in the side, and swelling appeared next 
day ; had rigors, and was feverish and vomited on November 28. On admission, pale ; 
some dyspnoea, but not urgent ; anxious expression ; a soft fluctuating swelling over the 
lower part of the left side of the chest, rather larger than the palm of the hand ; the heart's 
impulse was two or three inches to the right of the sternum, and the whole of the left 
side of the chest was dull, and the respiratory sounds were distant, though audible ; a 
cyrtometer tracing showed distinct bulging of the left side ; the abscess was opened the 
same day, and a small quantity of thin pus escaped ; the pleural cavity was then opened 
and a pair of dressing forceps pushed into it between the ribs ; a large quantity of slightlv 
turbid yellowish fluid was evacuated, the abscess cavity was clearly quite distinct from the 
pleura, and at that time the pleuritic fluid was not purulent ; the rib was bare, but not 
fractured ; a tracheotomy tube was tied into the chest and the wound dressed antiseptically. 
All went well, and on December 3 a vulcanite tube was substituted for the silver tracheotomv 
tube. On the following day it was seen that for the first time the discharge was distinctly 
purulent, and it was considerable in amount ; the lower half of the left chest behind was 
still dull and tender to percussion, though in front the resonance was good. Up to this 
time there was still partial orthopnoea ; a week later another abscess behind and above 
the first opening appeared, and, on incising it, bare bone was felt : the dullness &c. was 
clearing up. By the end of January 1882, the discharge from the chest had lessened and 
the dullness nearly disappeared. On February 2 an incision was made over the diseased 
rib, and about a third of it removed ; there was a good deal of new bone around the se- 
questrum ; the cavity left was plugged with a piece of sponge, which remained in place till 
March 6, when some of it was cut away ; several bleeding point? in it then appeared, due 
to granulations which had sprouted into it and held it firmly in position ; at this time the 
left base was normal, except slight dullness. On March 13 antiseptics were discontinued ; 
on the 20th more of the sponge was cut away, and at the end of the month the rest was 
removed ; it was found that it was impeding healing and causing eversion of the edges ; 
the sponge was filled with granulation tissue, which microscopically was seen to penetrate 
the unaltered sponge framework. The wound rapidly closed, and on May 5 he was dis- 
charged almost well; there was little if any retraction of the side, and the lung had 
apparently fully expanded. Here traumatic periostitis of the rib led to abscess externally 
and serous effusion into the pleural cavity ; after the opening was made probably the 
suppuration in the chest cavity resulted from the communication with the external 
abscess. 

Arrest of growth from destruction or synostosis of the epiphysial line may 
result ; l or, on the other hand, there may be overgrowth from persistent 
hyperasmia of the limb, as the result of the subsequent irritation caused by 

1 J. H. Morgan has detailed a case in the Brit. Med. Jour. September 1, 1883. The 
humerus was the bone affected. Vide also Tubby, Lancet, June 6, 1891. 



Chronic Periostitis 



597 



sequestra (fig. 1 18). This overgrowth may, as seen in the figure, cause dis- 
tortion from one bone of the limb outgrowing the other. 1 Occasionally 
relapses occur many years after the original disease has subsided, and 
abscesses form, and sequestra are separated in middle life. We have 
several times met with these cases of ' relapsed necrosis.' 

Where the periosteum has extensively sloughed, or where the bone has 
been fractured, a short, weak limb may result from deficient development of 
new bone ; these fractures sometimes remain ununited, and may require 
resection and wiring. 

Case. — Nonr-Union of Tibia after Fracture as Result of Necrosis. — Female, age 
4 years 5 months ; five months ago left hospital, after sequestrotomy, in a plaster bandage ; 
no union occurred, and limb was useless and quite 
movable, though not Hail-like ; incision made down 
upon ends of bone, which were much atrophied ; 
surfaces refreshed and wired together by one silver 
suture, which was fixed to buttons on surface of 
wound ; ultimately firm union occurred, and child 
could bear her weight upon her leg and walk well. 

As the accounts of different writers on 
the subject of acute bone inflammation are 
somewhat conflicting, and give rise to con- 
fusion, the accompanying tabular statement 
of how the different lesions may arise will 
perhaps be of service to those less familiar 
with bone diseases. 

Acute inflammation of bone may begin 
as : 

A. Periostitis. 

1. Sub-periosteal. 

2. Supra-periosteal or Parosteal. 

B. Osteomyelitis. 

1. Epiphysitis, i.e. disease beginning 

in the cancellous tissue of the 
epiphysis. 

2. Inflammation of the medulla of the 

shaft (diaphysitis). 

3. Inflammation beginning in the 

epiphysial line, often called epi- 
physitis also. 
Inflammation arising in any of these ways may give rise to the other 
forms of lesion ; e.g. snb-periostcal abscess may spread along the epiphysial 
line and cause suppuration in the medulla of the shaft, or inflammation ot 
the medulla may spread outwards and cause periostitis. As a rule, however, 
careful clinical observation will enable an accurate opinion to be given of 
the primal)- seat of the mischief. 




-Shows Overgrowth of the 
Bones of the Right Leg, especially 

the Tibia, after Neiro-is. (Dr. 
Massiah's case.) 



1 Birkett has recorded a case oi overgrowth of a limb after injury to the patella in a 
boy of eight years [Path, Soc. Trans, vol. xviii.) ; vide also Edmunds, 
1885. A case o( R Pollard's, described as hypertrophied 0. Uus, is perhaps of the same 
nature. 



598 Diseases of the Bones 

Chronic Periostitis. — Periostitis of less severity, and less rapid in pro- 
gress, is common enough, and the subacute cases are better classed with the 
chronic than with the acute, inasmuch as they are more like the former than 
the latter in their results. Subacute or chronic periostitis then occurs in 
children as the result of injury, as a pyaemic condition, or as the sequela of 
an exanthem — probably these two sets of cases are very closely allied, if not 
identical ; or it may be caused by syphilis or tubercle. Whichever of these 
is the cause in any individual case, suppuration often takes place except in 
traumatic and in many of the syphilitic cases. Since the process is a slow 
one, it is usually impossible to say whether the lesion began as a sub- or 
supra-periosteal inflammation ; perhaps the whole thickness of the membrane 
is involved at once, or else, as the bone is usually more or less deeply impli- 
cated, the lesion is sub-periosteal in origin. 

The disease is characterised by local or diffused thickening of the bone 
in its early stages ; the swelling is tender, painful at times, but usually, unless 
in subacute cases, there is no implication of the skin. Later on, the swelling, 
if left to itself, either subsides or softens down, and abscesses form in one or 
more spots ; on incising these the bone is found bare and rough, with perhaps 
small scale-like exfoliations, or in other cases, to be described presently, 
more extensive lesions. The periosteum is sometimes four or five times its 
usual thickness and readily peels off the bone, while in old cases there is 
often some rough spiny deposit of new bone developed around the centre of 
disease. In traumatic cases in healthy subjects the thickening may subside 
altogether without any trouble or suppuration, or there may be sufficient new 
bone formation to cause swelling lasting for months or years without any 
other symptom. 

In tubercular children the swelling ('strumous periosteal node') usually 
slowly increases, often painlessly, though by no means always so ; suppura- 
tion finally occurs and matter is discharged, or in rarer instances the inflam- 
mation subsides. Generally in the tubercular cases periostitis is either the 
result of, or itself leads on to, osteomyelitis. (Superficial or central caries.) 

Exanthematous periostitis is found usually in wasted and feeble children, 
either in the course of, or as a sequel to, one of the specific fevers ; there is 
often much suppuration, with but little pain or disturbance, and a limb is 
found occasionally to be little more than a flabby bag of pus, without any pain 
and without much fever. The child lies wasted and haggard, with rough scaly 
skin and offensive smell, the hair harsh and often thin, and the veins showing 
distinctly through the thin, fatless skin. The chronic pyaemic cases so 
exactly resemble these that it is probable that many of the exanthematous 
forms are really pyarmic. A fair number of such children recover, others 
gradually sink of exhaustion or some intercurrent pneumonia or diarrhoea. 
Much less severe cases are also met with, in which chronic periostitis occurs 
affecting only a small part of a bone — it may be any bone — and either sub- 
siding or giving rise to only local necrosis ; the ribs are said to be specially 
often attacked after typhoid fever, but seldom necrose. For an excellent 
account of these diseases vide T. Jones on 'Diseases of the Bones, ; 1887, p. 40 ; 
vide also chapter on Spinal Disease, infra, p. 620, for a case of necrosis 
of a spinous process. 

Congenital syphilitic periostitis is usually multiple, and occurs rarely 



SypJiilitic Periostitis 



599 



during the first year or two of life, being commonest from about the 5th to 
the 15th year. It is, as Hutchinson has pointed out, less amenable to anti- 
syphilitic treatment than the periostitis of acquired syphilis, and according 
to him is common in the upper limbs ; in our experience symmetrical 
periostitis of the shafts of the tibiae (' syphilitic nodes ') is far the commonest 
form, and in some cases it breaks down and large ulcers form on the surface. 
The amount of thickening may be enormous, as in fig. 1 19. 

Case. — Chronic Syphilitic Periostitis of Tibia. — Lilian G. , age 12 years ; admitted 
November 19, 1884. Mother had three miscarriages as the result of her three first preg- 
nancies. Patient when born had an erup- 
tion about the buttocks, sores round the 
mouth, and snuffles ; improved at six 
months old, and has gone on well since, 
•except for a sore eye. Duration, three 
years ; following a slight kick ; no swelling 
till a month later ; much pain ever since ; 
has been under treatment (antisyphilitic) 
as an out-patient for some considerable 
time. On admission, healthy-looking 
girl ; teeth normal ; no obvious signs of 
syphilis ; the right tibia is much thickened, 
and apparently bowed antero-posteriorly ; 
no fluctuation ; the most tender spot is 
on the front of the lower part of the 
middle third ; the swelling involves nearly 
the whole shaft ; no fever. November 27, 
tibia trephined at its most painful spot ; 
periosteum much thickened ; the bone 
was much sclerosed and the medullary 
•cavity reduced to a narrow channel ; no 
pus and no cavity found. The reflected 
periosteum was stitched together with 
•catgut and tube inserted. Operation 
antiseptic. All went well ; she was dis- _,«-*§p 
•charged on December 17 ; there was no %^^^j 
further pain, and when seen as an out- 
patient, February 1885, she was sound 

and well, and free from pain. „. _ . . „ ,.,... „ 

/-.~„ o ,rri' t-> • j-j- cr^-i- * >S- Il 9- — Congenital Syphilitic Disease of both 
CASK.— Syphilitic Periostitis Of Tibia. Tibia (periosteal and 'endosteal). This figure. 
— John Wm. A. , age 6 vears. No tuber- from a patient of our own. is reproduced "from 
cular history ; one of 'the children died Mn J ones ' s book - 
of convulsions at seven weeks — it had 

.snuffles; three other children living; no miscarriages. Child healthy at birth, weakly 
since three years old ; the leg has been tender for six months, but no swelling was 
noticed till four days ago ; no pain unless touched. On admission, pale, unhealthy 
child ; has remains of double interstitial keratitis and scars at the angle oi the mouth ; 
the upper milk incisors have gone, lower incisors small and ill formed ; there is thickening, 
forming a prominent swelling in the middle of both tibiae, tender but not rod. 
tenderness disappeared quickly under treatment (antisyphilitic), the -welling remaining 
much the same. 

Less frequently the upper end of the tibia is involved : in such cases 
there is not rarely effusion into the knee, not merely passive, but an actual 
serous synovitis. Other evidence of congenital syphilis Is in our experience 
almost always to be found, though it is not always obvious. The pain is 




600 Diseases of the Bones 

often severe, though sometimes it is almost absent. 1 Macnamara believes 
that the syphilitic telostitis of infants {see chapter on Congenital Syphilis) 
is due to interference with nutrition at the epiphysial line from pressure of" 
new-formed periosteal deposit around, and that the telostitis is not inflam- 
matory. 2 Arrest of growth may result just as in the case of older children 
who are attacked by syphilitic epiphysitis 3 {vide Epiphysitis). The palate 
and bones of the face are not rarely destroyed by congenital syphilis, but 
this occurs in a late stage of the disease {vide fig. 84) ; the nasal bones are, 
of course, early affected, and the deformity resulting gives rise to one of the 
characteristic features of inherited syphilis. The evidence afforded by 
thickening of the bone, with tenderness on deep pressure and aching pain., 
serves to distinguish periostitis generally from any more superficial lesion, 
while the onset of swelling and pain simultaneously points to the existence 
of periostitis rather than osteomyelitis, though either, it must be remembered, 
may give rise to the other. New growths are to be distinguished by their 
greater rarity, their greater prominence, with often bosses and a well-defined 
margin, and local patches of softening, as well as by their situation, which is 
usually at the ends of the bones ; hence they are more likely to be mis- 
taken for osteomyelitis than for periostitis. 

The tubercular and syphilitic lesions are nearly always accompanied by 
other evidences of their respective diseases, such as tuberculous glands or 
ulcers, a family history of tubercle, or, on the other hand, syphilitic lesions 
of the eyes, teeth, &c. 4 

There is difficulty sometimes in distinguishing the lesions of bone due 
to congenital syphilis from those dependent upon tuberculosis, though we 
are not inclined to think that the mistake is so often made as Fournier 5 
would have us suppose. As already mentioned, the tibia is (as Fournier 
also points out) the bone most commonly affected by the syphilitic lesions, 
and the long bones are more often attacked than the short or flat bones, 
with, perhaps, the exception of the skull, while the diaphysis is more liable 
to be attacked by syphilis than the epiphyses. New bone formation, severe 
pain, worse at night, little tendency to suppuration, though occasionally 
abscess and necrosis do occur, and evidences of syphilis from the history or 
presence of other syphilitic lesions, are the principal features of the one 
group, while the tuberculous cases are characterised by absence of any new 
bone formation, caries occurring rather than necrosis, by early suppuration,, 
freedom from pain, and the other features already pointed out. The effects 
of treatment by iodide of potassium will give confirmatory evidence. In 
any case of doubt antisyphilitic treatment should be given a fair trial, it 
being remembered that children bear, and often require, large doses of 
iodide (gr. x-xx) to obtain good results. Nearly all the varieties of 

1 Mr. Moullin has written a good paper on this subject in the Brit. Med. Jour. 1884, 
P- 52. 

2 Brit. Med. Jour. July 5, 1884. 5 Hutchinson, Lcndon Hospital Reports, vol. ii. 

4 Dr. Goodhart has met with a remarkable case of bone disease in a child a year old,, 
which was thought to bear relation to osteitis deformans, but was probably syphilitic ; 
there were tenderness, softening, and diffused thickening of the bone ; rickets cc-existed. — ■ 
Path. Soc. Trans, vol. xxxiv. 

5 La Syphilis Hiriditaire Tardive. Paris, 1886. To this work we must refer for an 
elaborate account of the later lesions of hereditary syphilis. 



... 



Syphilitic Periostitis 60 1 

periostitis are found chiefly in the long bones, though similar lesions may be 
met with elsewhere, as in the jaws, &c. ; vide chapter on DISEASES OF 
the Mouth, and also the chapter on Joints. 

Treatment. — In early stages of the disease, if the leg is affected the child 
should be kept in bed with a splint on. Cod liver oil and iron should be 
given in the tuberculous, hydrarg. c. creta or iodide of potassium in the 
syphilitic cases : the former in children one or two years old, and a com- 
bination of the mercury and iodide in older cases being the best treatment. 
Where the arm is affected, a splint should be applied and the child allowed 
to be up, unless any subacute mischief is going on. Simple traumatic cases 
require rest and the application of soothing lotions, such as lead, with or 
without spirit or opium, or the application of belladonna diluted with glycerine 
or vaseline ; in some cases good is done by rubbing in mercurial ointment, 
or better, ung. hydrarg. oleat. 5 or io per ct., or keeping it applied over the 
swelling. Some surgeons have faith in the application of iodine ; a blister 
is sometimes undoubtedly of use in relieving pain. If after a fair trial of 
some weeks no good result has been obtained by these means, and pain 
still persists, or, of course, earlier than this if suppuration occurs, an incision 
should be made down upon the bone through the periosteum ; if pus is 
found, or any superficial necrosis, the case is to be treated on ordinary 
principles : if after this the pain is not relieved or returns, it may be taken 
for certain that osteomyelitis exists, either as a primary or secondary con- 
dition, and this should specially be borne in mind in tubercular cases in 
which osteomyelitis is much more commonly the primary lesion in long 
bones. If then there is evidence of osteomyelitis, further measures will be 
required {vide pp. 605 et sea.). 

Occasionally in syphilitic cases no absorption takes place under mercurial 
or iodide treatment ; if the pain persists, the bone should be cut down upon 
and, if necessary, trephined or gouged, so as to open up the sclerosed bone 
and give vent to any pent-up material (cf. case, p. 599, anted). In cases of 
syphilitic necrosis of the bones of the face or palate a plastic operation may 
be required, but this should not be attempted until the destructive process 
has entirely ceased. Where the whole hard palate has been destroyed an 
obturator may be necessary. We have seen a case where, after ulceration 
of the palate and pharynx, the soft palate became adherent to the pharyngeal 
wall, and the obstruction to the nose thus produced caused so much trouble 
that excision of part of the soft palate became necessary. ' Periostitis 
albuminosa' is a name given to a form of periostitis in which there is 
effusion of non-purulent fluid beneath the periosteum. There may or may 
not be necrosis. There is no hard-and-fast line to be drawn between these 
cases and chronic purulent periostitis ; the exact nature of the effusion may 
in our experience vary from serum to solid lymph on the one hand or pus 
on the other ; a similar variation occurs in the case of the effusion in central 
inflammation. We have found the medulla replaced by masses of curd-like 
lymph with little or no pus. 

Acute osteomyelitis. Acute diffuse infective osteomyelitis occurs 
usually as a result of amputations or resections, but is rare in this country ; 
it is, however, more common in hot climates. The disease is, however, here 
most often met with as a result of extension to the medulla oi inflammation 



<6o2 Diseases of the Bones 

beginning in the epiphysis or epiphysial line, or of acute periostitis, and 
occasionally occurs as a primary condition. Mr. Macnamara, and with him 
some of the continental surgeons as already mentioned, believe that the 
affection already described as acute periostitis is really acute osteomyelitis ; 
this, however, is, we believe, not the case as a rule, since if it were so complete 
recovery in these cases without extensive necrosis Avould not be nearly so 
common as it is. Moreover, in cases of acute periostitis dying of pyaemia 
sections of the bone have shown an entire absence of osteomyelitis in some 
instances. 

The characteristic symptoms, in a case where acute osteomyelitis follows 
amputation, are swelling and subsequent suppuration of the medulla, retrac- 
tion of the periosteum and soft parts, so that the bone is left bare, and 
diffuse swelling of the limb. Pyaemia usually rapidly ensues, and in many 
cases death speedily results. Amputation at the joint above has been 
usually said to be the only successful method of treatment, but the plan 
introduced of scraping out the entire contents of the medullary canal, as 
advocated by Mr. Keetley and others, is well worthy of adoption, and has 
proved successful in several instances ; our colleague Mr. T. Jones, among 
others, has had good results from this method. 

Where acute diffuse osteomyelitis occurs as a sequel to epiphysitis or 
periostitis, or is the primary lesion, the shaft of the affected bone should be 
freely opened with trephine or chisel, and a similar treatment adopted. The 
existence of this disease may be suspected, as already pointed out, when the 
severe constitutional symptoms and pain do not subside after freely incising 
the periosteum or opening up an epiphysial abscess ; swelling and tenderness 
at one or more points in the shaft, or diffuse bony swelling without any col- 
lection of fluid beneath the periosteum, will indicate the presence of pus in 
the medulla. For an excellent account of the whole question vide ' Diseases 
•of the Bones,' by T. Jones, 1887. 

Acute Epiphysitis. — Acute circumscribed osteomyelitis or acute epiphy- 
sitis is a more common condition ; it consists in a localised inflammation 
attacking the cancellous tissue of an epiphysis or the immediate neighbour- 
hood of the epiphysial line. The disease nearly always goes on to suppura- 
tion, and on examination a cavity will be found containing pus, or in some 
cases sequestra. Acute epiphysitis may occur in children of any age : for 
instance, most cases of 'acute suppurative arthritis of infants' are typical 
examples of this disease {vide p. 622) ; in other, though much rarer, instances 
-older children are attacked. 1 

If left to itself, the pus finds its way either into the adjacent joint or along 
the epiphysial line to the surface (the epiphysis may in this way become 
detached from the shaft), or down the medulla of the shaft, giving rise to 
acute diffuse osteomyelitis. The disease may follow an injury or exposure, or 
•one of the exanthems, or, according to Mr. Greig Smith, may arise from 
lymphatic infection of the bone marrow. It most commonly attacks the 
head of the femur, the upper end of the tibia, or the lower end of the femur, 
less often the extremities of other long bones. Some of the cases of acute 
disease of the hip, elbow, shoulder, and ankle, apart from ' acute suppurative 
arthritis of infants,' are really also of this nature. 

1 Vide Abstracts of Cases treated at Children's Hospital, Pendlebury, 1882. 



Acute Epiphysitis 603 

The lesion is marked by early fever and much pain, 1 of gnawing, tooth- 
ache-like character, followed, after a longer or shorter time, according to 
the age of the patient and the amount of resistance to the exit of the pus, 
by swelling of the bone coverings and effusion into the adjacent joint, which 
is usually kept fixed in the position of least tension. We have, however, 
seen the knee strained to its utmost degree of flexion, far beyond the point 
of least tension ; thus showing at once that the lesion could not be intra- 
articular. 

The pain is usually agonising, and the failure of health very rapid. Deep 
pressure in the earlier stages, and any touch of the limb when the pus is 
approaching the surface, is exceedingly painful. Local heat is usually only 
appreciable in the later stages ; increased pulsation in the main artery of the 
limb may be found. In infantile arthritis (acute suppurative arthritis) the 
symptoms are sometimes subacute. The diagnosis is made by careful 
exclusion of joint lesions (by lack of marked effusion, &c), where the joint is 
still free, and attention to the history of the pain and swelling, so as to dis- 
tinguish the case from periostitis, though, of course, as pointed out by 
Macnamara and others, and as already described, epiphysitis may give rise 
to sub-periosteal abscess and necrosis as well as to intra-articular abscess ; 
pain on deep pressure in the absence of joint disease is a characteristic 
feature. Rheumatism and rickety pain are readily distinguished by the 
strict localisation of the suffering. In the infantile cases the joint is usually 
involved by the time the child is brought. 

CASE. — Abscess in the Head of the Tibia. — Wm. Hy. D , age 9 years ; admitted 
December 30, 1881. Had pain in the leg for two months ; worse for five days ; no fur- 
ther history. On admission he was pale, ill, and anxious. Temperature io3 - 3° ; there 
was intense pain in the right knee, which was flexed to its fullest extent ; there was no 
effusion in the joint, and the outlines of the condyles were distinct through the tightly 
stretched skin. Over the head of the tibia and the upper third of the leg there was con- 
siderable swelling, most marked over the inner tuberosity of the tibia, where also the 
tenderness was greatest ; no fluctuation ; under chloroform an incision was made over the 
inner tuberosity, and the soft parts found infiltrated with inflammatory products, but no 
pus ; a chink indicating the line of union of epiphysis and diaphysis was seen, and on 
gouging away some bone about dr. ss. of thick sanious pus escaped ; no distinct cavity 
was found ; operation antiseptic ; a tube was put into the opening in the bone ; one hour 
after, the temperature was 102 - 6°. He had pain on several evenings subsequently, and 
there was but little non-purulent discharge for two days, when several drachms of pus were 
discharged. On January 5, as the joint was swollen, it was aspirated, and a small quan- 
tity of turbid sanious fluid withdrawn and an ice bag applied ; he had no pain afterwards, 
but on the 12th the joint began again to swell, and on the 15th was distended, ami in- 
cisions were made into it, discharging fluid, at first flaky, but serous, and subsequently 
more nearly purulent. On February 9 the drainage tubes were removed and .ill w as going 
on well, the wounds in the joint being superficial, though bone could be felt through the 
opening into the tibia ; the limb had been kept fixed. On the 23rd the joint was forcibly 
flexed and several adhesions broken down ; considerable swelling followed ; the joint 
shortly settled down again. March 3, a small sequestrum was removed from the tibia as 
well as a good deal of caseous material. April 3, the limb was put up in plaster o\ Pans, 
and the boy sent out on the 5th. He attended as an out-patient subsequently; several 
small hits of bone came away, but the wound finally closed, and he has now, February 
1883, a sound limb with a fully movable knee, though a little thickening stilljen 

1 In the infantile eases we have, of course, no means of knowing the kind of pain, but 
usually it is evidently severe. 



604 Diseases of the Bones 

The treatment of acute epiphysitis consists in early and free incision 
down to the bone ; if matter is met with, this is usually sufficient, but, should 
the pus not have reached the surface, an opening must be at once made into 
the bone and the abscess emptied, any sequestra found being removed. In 
any doubtful case it is far better to explore the bone than to run the risk of 
the abscess bursting into the adjacent joint. Should the joint be already 
involved, as it almost always is in the acute epiphysitis of infants, it must be 
freely opened and drained. For a more detailed account of infantile epiphy- 
sitis, see the chapter on Diseases of the Joints, p. 612. Messrs. Pick 
and Page have recently called attention again to these cases which have 
been described above, and discussed both in former editions of this book 
and elsewhere. 

Should the mischief have spread to the medulla of the shaft, the diaphysis 
should be exposed and trephined at one or more spots to give vent to the 
pus, and the whole medullary cavity should be scraped out, washed, and 
drained ; failing this, amputation is the last resource. For some good cases 
illustrating this treatment, vide T. Jones on 'Diseases of the Bones,' 1887,. 
and 'Medical Chronicle,' Dec. 1886. 

A condition known as ' Growing Fever ' is sometimes met with, usually 
in children of from seven to fifteen years, though occasionally at both earlier 
and later ages. The main features are pain in the region of the epiphysial 
lines, rapid growth and fever sometimes, with considerable constitutional 
disturbance. Usually the symptoms pass off without any bad result, but in 
rare cases osteomyelitis may be set up, and the development of exostoses 
about the epiphysial lines has also been noticed after the occur- 
rence of -growing fever : {vide 'British Medical Journal,' April 14, 1888, 
p. 820). 

Chronic Circumscribed Osteomyelitis. — Where chronic osteomyelitis 
is localised, as, for instance, sometimes in the epiphysial extremities of the 
long bones, an abscess may result, with or without necrosis ; the symptoms 
are those of acute epiphysitis, already described, only less severe, and the 
onset of the disease is slower and more insidious. In non-tubercular cases 
there is often much sclerosis of bone around the abscess cavity, and the 
disease may go on for years without any attempt at reaching the surface. 
In other instances the extension of the inflammation to the surface is marked 
by slight and slowly increasing thickening of the periosteum, so that the 
diameter of the bone is somewhat increased, and the tissues over it may be 
slightly cedematous. The characteristic aching, gnawing pain, especially at 
night, is sometimes well marked, but in children more often there is com- 
paratively little pain, and the pus soon finds its way to the surface — both 
these facts being due, no doubt, to the less resisting nature of the softer 
bones of children. Hence the more typical features of chronic circumscribed 
abscess of bone are comparatively seldom seen in young children, but are 
most marked in young adults. Moreover, in children the distinction between 
circumscribed and diffuse osteomyelitis is also less defined ; though sclerosis 
of the walls of the cavity does sometimes occur, it is less frequent in children, 
and the inflammation is more apt to become diffuse. The attacks of pain 
may be intermittent, so that for weeks or months there is little sign of any- 
thing wrong, and then all the symptoms reappear. 



Abscess in Bone 



Go- 



Case. — Epiphysitis of both Femora, dfc. — John W. , age 6 ; admitted April 12, 1884. 
Always delicate ; for eighteen months past had abscesses ; twelve months ago had dropsy ; 
eight months ago had measles ; four months ago knee swelled painlessly, was poulticed 
and opened. On admission, delicate child ; abscess scars about neck, &x. Sinus over 
left upper arm leading to bare bone. Just above right knee is a sinus, and two more in 
popliteal space, another below the knee ; at lower third of leg is a large abscess ; sinuses 
also round left knee. 18th, abscesses on leg and knee opened ; 21st, sent out for a 
while. Readmitted May 19. June 3, explored, and bare bone felt at back of right knee 
and iif arm. June ir, under chloroform. Left thigh explored through incision on outer 
side ; no bare bone felt, and posterior triangular space was healthy, but bone was enlarged, 
so a circular opening was made with 
a gouge, and deep in the centre of the 
bone was found a cavity containing 
pus and pus-infiltrated bone ; on clear- 
ing out this a cavity the size of the 
top of the thumb was left with scle- 
rosed walls. On the right side bare 
bone was felt behind and above the 
internal condyle ; a precisely similar 
operation was done and just the same 
condition found, together with several 
small hard sequestra. This cavity 
communicated by a circuitous course 
with the sinus on the outer side ; this 
was only found out by injecting lotion. 
A small sequestrum was also removed 
from the humerus. Wounds syringed 
out with chloride of zinc and filled 
with iodoform. Some cellulitis &c. 
followed, but he did fairly well up to 
a certain point and was discharged 
July 31. He was subsequently re- 
admitted with the disease in the right 
thigh extending, and was still under 
treatment in 1892. He is now lost 
• sight of. 

Abscess in bone is not limited 
to childhood, but very frequently 
begins before puberty, though 
many of these patients do not 
come under treatment until the 
disease is of long standing. 
Though most commonly met 
with in the cancellous tissue of 
the extremities of the long bones, abscess may also occur in the shaft, and 
Ave have more than once had to trephine for circumscribed abscess in the 
middle of the shaft (of the femur or tibia) occurring many years after .111 
attack of acute periostitis. 

T>ratmcnt.—\s in acute periostitis, there is but one thing to be clone in 
these cases. A free incision should .it once be made down upon the bone, 
and, either with a gouge or trephine, a hole made into the cancellous issue 
until the abscess is reached. Before operating the exact spot oi greatest 
tenderness should bo marked, and this is to be the centre of the incision. 
We have derived great help from this precaution in finding a small abscess 




Fig. 120- Epiphysitis of the upper end of the right 
Humerus, with softening and relaxation of the ligaments 
ofthe Shoulder Joint. The joint cavity was not lrr\ olved. 



606 Diseases of the Bones 

in bone. Some surgeons prefer to do linear osteotomy, i.e. saw across the 
epiphysis with a fine saw, and thus open up the abscess ; but this plan is in 
no way better than the other. The bone is usually found soft, red, and 
rarefied ; often only a drop or two of pus will escape, and this may be 
overlooked. Even if the abscess is not found, relief is almost sure to 
follow, and pus will be discharged in a day or two : at the same time, if no 
abscess is found, careful exploration should be made in every direction for 
the matter, to diminish the risk of its opening into the joint. Should a 
sequestrum be found, it will be of course removed, and the cavity should be 
well scraped out and drained ; should the adjacent joint be involved, it 
must be treated like any other suppurating joint. 1 

Chronic diffuse Osteomyelitis.— This disease is met with chiefly as a 
tubercular or as a pyemic condition ; it may result from extension from a 
primary periostitis, or originate in the medulla, perhaps most often beginning 
in the epiphysial line. It is a matter of extreme difficulty, and sometimes 
impossible, to be sure whether a given lesion has begun as a local periostitis,, 
spreading afterwards to the epiphysial line, or whether the epiphysial lesion 
is primary and the periostitis secondary. 

The tubercular disease in a well-marked case is a remarkable lesion ; the 
child has perhaps a history of some long-continued bone trouble coming on 
after measles or other illness, or after an injury ; external examination shows 
thickening of a large part of a long bone, with a sinus leading down to a cavity 
in the shaft. At first sight it appears that the case is one in which either the 
periostitis is the main lesion, or a small localised central inflammation has 
reached the surface and then spread along the periosteum ; but on cutting 
down upon the cavity, and clearing it out, a small sequestrum, infiltrated 
with pus, and greenish-yellow in colour, is removed. Instead, then, of 
finding the walls of this cavity formed of healthy but sclerosed bone, 
they are soft and also infiltrated with pus, showing the same greenish colour 
as the sequestrum. There is no sharp line of demarcation between this 
green bone and the surrounding shaft, but patches of rarefied pale bone are 
seen in parts. On attempting to gouge away the diseased tissue it will often 
be found to extend throughout a great part of the shaft, and perhaps several 
inches of cancellous tissue are thus removed before living bone is reached. 
When all has been removed the cavity slowly fills up, leaving a sinus or two. 
Some months after, on exploring these sinuses, a similar condition is found ; 
the purulent infiltration has again gone on spreading, and in time it may 
reach an adjacent joint and set up disease there. In such cases the compact 
tissue is usually healthy in appearance, though sometimes it is perforated, 
and there is generally some, but not always great, periosteal thickening. In 
other instances, where the changes have been rather more active, the diseased, 
part becomes isolated and sequestra are thrown off ( ; chronic circumscribed 
osteomyelitis,' 'central necrosis '). Sometimes the compact tissue also dies 
(' total necrosis '). Though this disease most commonly affects the long 
bones, it may, as already pointed out, attack the jaw ; here even the new 
bone may become infiltrated, and die as fast as it is formed ; it is, however, 

1 The subject of acute suppurative arthritis in infants (acute epiphysitis) is treated more 
specially under Diseases of the Joints. 



CI ironic Osteomyelitis 607 

doubtful whether this condition in the case of the jaw is tubercular {vide 
Diseases of the Alimentary Canal). 

Case. — Alveolar Abscess, Necrosis of Jaw. — Joseph P., age 6 years; admitted May 
31, 1884. Fairly healthy till four months ago, when he had toothache ; tooth extracted, 
but swelling did not subside. On admission, much swelling over right side of lower jaw. 
From socket of first lower molar, which is gone, pus and granulation tissue exude. 
June 4, alveolus cleared out ; some small pieces of bone and a rudimentary permanent 
tooth removed. Discharged June 4. Readmitted June 23, with more pain, swelling, and 
discharge ; external incision made and pus let out. June 26, swelling &c. increased ; a 
large sequestrum removed from inside the mouth, and several more through the external 
opening ; these sequestra were soft, foetid, and pus : infiltrated, and formed part of the 
horizontal and ascending rami throughout their entire thickness ; the cavity left extended 
nearly up to the joint ; some new bone had been formed and died subsequently. July 9, 
discharged much relieved. 

The scapula, clavicle, ribs, pelvis and sternum, and facial bones are also 
sometimes attacked, and disease of adjacent joints may occur by extension. 
Though the malar and upper jaw bones are often affected, we have seldom 
seen any of the bones of the vault of the skull attacked, except the temporal y 
and this has been a result of disease of the ear. The occipital we have 
once seen perforated by tuberculous disease, and in the same child the 
frontal bone was carious. The process is essentially alike in all these cases. 
The sequestra are generally soft, and in some cases the pus decomposes and 
they become foetid, but this is not by any means generally so in the limb 
bones. 

A similar condition is found in the epiphyses of the long bones without 
the shaft being involved ; sometimes a whole epiphysial nucleus will die 
and shell out as a sequestrum. We have met with the same condition in 
the patella, leading to destruction of the knee joint. 1 

CASE. — Necrosis of the Patella. Disease of Knee Joi7it. — John R., age 7^ years ; ad- 
mitted July 7, 1882. Ten weeks ago had a blow on the left knee, which became painful a 
week later. On July 2 it began to discharge ; his health had been failing since an attack 
of whooping cough eighteen months ago ; phthisis in family. On admission, a fluc- 
tuating swelling mapping out the left knee joint, a little redness and venous turgidity ; a 
half-closed sinus lay over the ligt. patellae ; limb nearly straight ; no pain. July 18, sinus 
explored ; it was found to lead upwards into a cavity in the patella, from which a seques- 
trum, the size of a damson stone, was removed. The joint was incised on each side and 
a free communication found to exist between the joint and the sinus through the patella ; 
coagulated lymph and serous fluid escaped from the joint ; operation antiseptic. August 
17, has dene well, and line of incision was healed except at entry of drainage tube ; very 
little discharge; general condition good; no fever since operation. August 29, dis- 
charged in a back splint ; readmitted in October ; wounds healed ; passive movement 
attempted, but adhesions found to be strong and universal, not giving any hopes of 
a movable joint, so he was fixed in a back splint with plaster of Paris, and sent out 
November 15. 

In this chronic osteomyelitis an epiphysial line acts only as an imperfect 
barrier, and, where the disease begins in it, it usually spreads both upwards 
towards the joint and downwards into the shaft. When the whole epiphysis 
is involved, the articular cartilage may be exposed on the removal ot the 
infiltrated bone, ami, as its nutrition is cut off from the side o\ the bone, it 

1 Vide Lancet, March 1883; also Children's Hospital Abstracts, 1882. Since then we 

have seen two or three similar cases. 



608 Diseases of the Bones 

usually gives way, and in such cases the joint becomes involved. We have, 
however, seen a case where complete recovery with a movable joint occurred, 
although the articular cartilage was thus exposed. 

Case. — Osteomyelitis of Tibia. — Annie L. , age 3 years ; admitted November 4, 1884. 
History good. In June 1884, fell downstairs ; in August first complained of pain in 
left leg ; it then began to swell, and has been slowly increasing ever since — rapidly during 
the last fortnight ; health failing ; has pain at night, &c. On admission, tense swelling of 
nearly the whole tibia and the soft parts over it ; skin shining, but not red ; temperature 
98 , 6°. Three incisions were made over the front and outer side down to the bone, but no 
pus escaped. She was relieved, pain disappeared, and swelling subsided. She was dis- 
charged on November 18. Readmitted December 16, 1884. The left tibia is enlarged in 
nearly its whole length, and is very tender on palpation over its lower third. Some pro- 
minence of superficial veins just above the ankle, but no discoloration of skin and no 
fluctuation; temperature normal. January 8, under spray, incision made over tibia just 
above the ankle ; periosteum found much thickened ; a small gouge was easily pushed into 
the centre of the bone, and some pus welled up ; a quantity of soft disintegrating bone, 
infiltrated with pus, was gouged away until a fairly healthy surface was reached ; drainage 
tube inserted ; iodoform and wood-wool dressing. On January 19 tube removed ; and on 
February 2 wound almost healed, but leg not diminished in size, and presents same 
general characters as on admission. Readmitted March 30, 1885. The wound from last 
operation has not healed, and is still discharging ; swelling has spread up the tibia as far 
as knee joint ; considerable thickening. April 30, no change in condition ; temperature 
occasionally ioo° at night. Esmarch's bandage applied, and incision afterwards made, 
about 2.\ inches long, over lower third of tibia ; periosteum detached and a new casing of 
bone, about \ in. thick, exposed ; on cutting through this with a chisel, softened bone 
infiltrated with pus was removed, and at lower end a sequestrum about 2 in. long was 
extracted. A second incision was afterwards made over upper third of tibia, and the bone 
found in similar diseased condition ; the whole of the interior of the tibia was gouged and 
scraped out, so that a probe could be passed from the upper to the lower opening ; iodo- 
form and wood-wool dressings and back splint applied, May 26, lower wound healing ; 
still large cavity at upper ; nvich discharge ; temperature hectic, 96 - 4°-ioo"4° ; takes food 
well. June 9, wounds slowly filling up ; suppurating glands at angle of jaw op?ned ; 
temperature 98°-io2°. June 29, wounds superficial, but still much discharge. July- 20, 
lower wound almost healed ; uppsr filling up and contracting ; less discharge ; tempera- 
ture normal. August n, still slight discharge from both wounds; sent home on back 
•splint. Readmitted October 24. Leg more swollen than when last in hospital ; still two 
sinuses over left tibia. The limb was finally amputated, as the joint became involved. 

The other forms of diffuse inflammation which may attack the marrow 
of bones have been already mentioned : in the rarefying form the medulla 
may be replaced by deep red or maroon-coloured granulation tissue, and 
the bone may become so soft as to readily break down under the finger ; 
such condition may, however, be recovered from. We have known a case 
where the femur was so affected, and recovery took place without any 
unusual difficult)'. 

In sclerosing or condensing osteomyelitis the medullary cavity may be 
almost entirely filled up with irregular dense masses of bone, and sometimes 
isolated central sequestra exist under such circumstances. 1 

Scattered miliary tubercles may sometimes be found in the medulla ot 
bone as a part of a general tuberculosis ; they are, however, only found post 
mortem, as they give rise to no symptoms during life. 

1 A combination of these two conditions appears to have existed in a case recorded by 
Mr. Paul in the Med. Press and Circ. 1884. 



Strumous Dactylitis 609 

The pyaemic variety of osteomyelitis is occasionally met with. In one of the most 
characteristic cases that we have seen, a boy eleven years old, who was in the habit of 
getting wet and drying his clothes on him, complained of pain in the feet ; the right foot 
and subsequently the knee swelled, the latter suppurated and discharged profusely a fort- 
night later ; the left elbow, the right hip, and the left knee then were attacked. On 
admission, ten weeks after the onset of the illness, both hips, both knees, and the right 
ankle, the left elbow, and the left shoulder, were swollen ; there were bedsores, and he 
had a systolic murmur and some evidence of pneumonia ; the urine was albuminous ; he 
was much wasted, and his skin was dry and harsh. A month after admission the left 
elbow was incised ; at that time there was brawny thickening over the upper part of the 
same arm ; ten days later, on exploring the humerus, there was found to be extensive but 
ill-defined mischief in it ; a fortnight after, the disease had extended so that the whole 
humerus was the seat of osteomyelitis ; pus discharged freely from the medulla at the 
upper part of the bone. The limb was amputated at the shoulder joint ; in doing so a 
large axillary abscess was opened. The shoulder joint was healthy, the elbow disorganised ; 
there was a sequestrum at the surgical neck of the humerus. He recovered fairly well 
from the operation, but subsequently fresh mischief occurred in the thigh, and he was 
removed by his friends, probably to die. 

Treatment of Chronic Osteomyelitis. — The treatment of the different 
forms of chronic osteomyelitis has been almost sufficiently indicated in the 
description of the disease. The general management will be that of 
tuberculous children : locally, in the early stages, rest to the part by means 
of splints, and in some cases confinement to bed, is all that can be done. If 
the disease does not subside, the bone must be freely exposed — the limb 
having been made bloodless by the elastic bandage, and the bone gouged away, 
all tissue that is dead or infiltrated with pus being removed ; if the mischief 
spreads far along the medulla, a groove must be cut in the bone, and all 
affected cancellous tissue scraped away. Should no repair take place and 
the disease spread to an adjacent joint, if the child's health is good, an 
attempt may yet be made to save the limb by incising the joint and draining 
it ; in some cases, however, nothing seems to arrest the disease, and ampu- 
tation is required. 

Washing out cavities with carbolic or mercurial lotion (1 in 4,ooo\ and 
free dusting with' iodoform, is perhaps the best wound treatment. In some 
cases it is a good plan to try the application of the actual cautery to the in- 
terior of the bone, in the hope of arresting the tubercular process. In pysemic 
cases incision of abscesses, removal of sequestra, and amputation are the only 
local resources, and each case has to be judged on its own requirements. 

'Strumous Dactylitis. '-The condition sometimes called 'strumous 
dactylitis' requires brief mention here. The disease is simply chronic tuber- 
culous osteomyelitis, or more rarely periostitis, attacking usually the first 
phalanx of one or more fingers ; sometimes the metacarpal or metatarsal 
bones are affected. The disease usually begins as a hard, painless swelling 
of that segment of the finger, though occasionally there isagoodde.il of pain, 
and always some tenderness. If no treatment is employed, the swelling 
increases, the soft parts become involved, abscesses ' appear usually at the 

1 1 1 must be understood that here as elsewhere the words ' abscess ' and ' pus 1 a 
1 (Mat ion to tuberculous lesions, used in a sense implying the naked-eye appearance rather 
than tin- actual pathological condition. The'pus' is broken-down caseous tubercular 
materia] diluted with serum, and mixed with simple inflammatory products, and nol 
true pus o( an acute abscess. Vide Watson Cheyne's Lectures, B it, M 
for a good description of the process. 

R R 



g I0 Diseases of the Bones 

sides of the finger, and on their bursting or being opened thick curdy pus, 
with perhaps, some bony detritus, escapes. On further examination, a arge 
cavity is found occupying the site of the old shaft, which ,s either entirely 
.one or remains in part as a cheesy sequestrum, or m some cases, if the 
abscess is opened early, appears to be simply bare. Around the cavity, 



s 






Fig. i2i„— Multiple 



i 



'ubercular Dactylitis.' 




/ 7\7% 



v> 



Y[cr 122.— Shows overgrowth ot one Thumb, 
which had been long the seat of Tuber- 
cular disease. This is a rare condition , and 
should be compared with fig. 118 ot over- 
growth of the tibia. 



which is filled with pus and caseous matter, is a thin layer of new bone 
formed bv the periosteum. As successive layers of new bone have been 
"own and "absorbed, so-called 'expansion' of the bone has ocenrr^ 
After removal of all the cheesy matter and sequestra the finger ma 
gradually shrink and get well, but is shortened, distorted, and usually weak 





I 



Fig. .33. -The hands of an adult showing the effects of Tubercular Dactylitis in childhood. 

and useless Sometimes the destruction is so great that amputation is 
reanired When seen in the earlier stages, constitutional treatment, with 
fixat on of the finger on a splint and gentle pressure, will sometimes succeed 
fn a restin' the disease. It has been recommended to excise the bone sub- 
flnv in the earlv stasre and this would no doubt cut short the disease, 
ESr&S^Wft: of much use. It is better treatment to wait 



Syphilitic Dactylitis — Leontiasis Ossea 6 1 1 

patiently, and keeping the finger quietly fixed on a splint to try the effects 
of pressure and general hygiene ; when sequestra are present they must, 
of course, be removed, and should no progress be made the cavity must be 
•cleared out—but, as a rule, a more useful finger is obtained by expectant 
than by active treatment. 

Should, however, abscess form, the best plan is to freely open and 
carefully scrape out the abscess cavity, removing all caseous material. The 
cavity should then be well dusted with iodoform and boric acid or some 
iodoform emulsion injected, and the wound should be closed by sutures 
without drainage. Primary union will usually be obtained if the wound is 
kept aseptic. 

Often many fingers are affected, and the disease is most commonly a 
part of ' General Surgical Tuberculosis ; ' it is most frequently met with in 
the first few years of life. The disease is probably sometimes periosteal 
rather than endosteal. 

'Syphilitic dactylitis,' so called, is more often described than met with. 
The general appearance closely resembles that of ' strumous dactylitis,' and 
it is said that in children the disease is usually primarily an osteomyelitis, 
though the gummatous material may be deposited first either in the peri- 
osteum or soft tissues overlying it. The occurrence of ' dactylitis ' in a child 
showing other signs of congenital syphilis would lead to a suspicion that the 
.affection of the fingers was also specific. The results are usually very much 
the same as those of the tuberculous lesion, and the treatment is simply that 
of syphilis. ' 

' Leontiasis Ossea' is a disease in which the bones of the face, especially 
the upper and lower jaws and the malar bones, undergo hypertrophy. The 
disease begins in early life and may go on indefinitely. In a case we saw 
which had been under the care of Dr. Brown, of Bacup, and Mr. T. Jones, the 
•disease began at 9 years old, and the patient when we saw him was 28. 

1 Vide Eschle in Langenbeck's Archiv, xxxvi. 1887 ; or an abstract in ftged. CAron, 
February i388. 



612 Diseases of the Joints 



CHAPTER XXVII 

DISEASES OF THE JOINTS 

Diseases of the Joints. — There is no essential difference between the 
joint diseases of children and those of adults, but certain forms of disease 
are found most typically, or even almost entirely, in childhood. The con- 
ditions of growth as regards the relations of epiphyses to the adjacent joints 
and to the shaft of the bone are, however, most important factors in deter- 
mining the occurrence of disease and the kind of lesion met with, and, 
further, the liability of children to the various exanthemata is of much 
importance in regard to joint affections. Ordinary acute synovitis from 
injury or cold is in no way peculiar to, nor even specially common in, 
children, and need not be discussed here ; while hip disease, acute sup- 
purative arthritis of infants, scarlatinal synovitis, and even the common 
tubercular pulpy disease, are instances of the modifying effects of the condi- 
tions of childhood upon forms of lesion which are also to be met with in adults. 

In early life the lesions of joints are more complex than in adults, for 
the reason already alluded to, that not only may disease begin in the joint 
structures, proper, but it may often reach the articulation by extension from 
the neighbouring epiphysis or epiphysial line. It is generally said that bone 
lesions are limited by the epiphysial zone and do not extend to the bone 
below ; this, as already shown, is only partially true, and, besides this, disease 
spreads frequently from a starting point in the epiphysial line, or from the 
periosteum of the diaphysis, and extends to the capsule, and so to the synovial 
membrane. There is, however, often effusion into a joint adjacent to bone 
disease without actual continuity of disease. (For further details see chapter 
on Bone Diseases.) 

Joint disease, then, in children may arise as a simple acute serous 
synovitis, which may subside, suppurate, or become chronic. Chronic 
simple serous synovitis is, however, rare in children. There may be 
a primary acute or chronic tubercular synovitis. Pyaemia or certain of the 
exanthems, notably scarlatina and typhoid, may give rise to an acute, some- 
times suppurative, synovitis, while measles and whooping cough, as well as 
scarlet fever and typhoid, may result in a development of tubercular lesions. 
Finally, the joint disease may arise by extension from the shaft, epiphysial 
line, or from the epiphysis itself, and possibly from the ligaments and 
tendon sheaths in exceptional cases. The specific fevers are not so often, 
as is sometimes stated, the direct cause of joint disease : it is in most cases 



Pathology of Joint Diseases 6 1 3 

rather that the depressing effect of the fevers makes the child more liable to 
the onset of disease — thus of 125 cases of joint disease, taken consecutively 
from our records, including cases of disease of the hip, knee, shoulder, 
■elbow, ankle and tarsus, and wrist joints, in only six cases was the joint 
affection a sequela of measles, in four of scarlet fever, in two of typhoid, and 
in three of whooping cough. Only those cases were reckoned in which there 
was no interval of health between the exanthemand the joint trouble. 

In certain joints bone lesions are far most commonly primary, as in the 
hip, and perhaps the shoulder ; in other joints, as in the knee, ankle, and 
wrist, bone disease when present is much more often secondary to a primary 
synovial inflammation, while in other joints again, as in the elbow, either 
starting point is common. 

The hip is by far the most frequently diseased joint in children, and the 
knee comes next. Of 698 cases of joint disease under our care in the out- 
patient department of the Children's Hospital in three years, 369 were cases 
of hip disease, 160 of knee disease, and all the other joints together amounted 
to 169. Disease of the spine is excluded from this calculation. 

For any detailed account of the pathology and symptoms of each diseased 
joint we must refer to the special works of Barwell, Macnamara, Howard 
Marsh, Hueter, and others ; space will only allow of selection of the hip and 
knee as types of the two forms of joint disease found in childhood, with a 
brief reference to the other most commonly affected articulations. Hip 
•disease stands so much by itself that its consideration will be most con- 
veniently postponed till after that of the other joints. 

Chronic disease of the knee joint may be taken as the type of joint 
disease beginning in synovial membrane — pulpy disease, chronic synovitis, 
tubercular synovitis, white swelling, and various other titles, all implying the 
same condition. 

Here we may say at once that we believe all the cases of chronic dis- 
ease of joints marked by great thickening of synovial membrane, with little 
or no tendency to accumulation of fluid, but with great tendency to the 
formation of small multiple abscesses in the thickness of the gelatinous 
tissue, are truly tubercular in the most strict sense. In some cases a consider- 
able amount of fluid, either serous with caseous material and flakes of lymph, 
or more puriform, is found in the joint ; this is, however, not a common con- 
dition in children. In many instances evidence of tubercle elsewhere and a 
tubercular family history will be found ; ' in many, death ultimately results 
from tuberculosis of other organs. The anatomical characters of tubercle 
are constantly to be found in the pulpy tissue, and, though not so constantly 
or readily, yet in a large number of instances tubercle bacilli have boon 
detected. 

The usual history of a case of chronic tubercular synovitis o\ the knee 
joint in a child is as follows. There is perhaps a history oi phthisis or joint 
disease in the family ; the child has been health}-, till at the age of,say, four 
years it was attacked by measles or some other exanthem. It was slow in 

1 In [92 histories of chronic joint disease under our care (the spine being included), in 
l.; ( c doubtful cases) there was .1 tubercular family history ; in cm ( 1 doubtfu - 

disease had followed an injury. In u> cases out of m patients there was mo:, 
lesion, i.e. there was evidence o( tubercle elsewhere. 



6 14 Diseases of the Joints 

recovery, and was never quite strong afterwards : a year later, perhaps, it 
received some injury to the knee. Shortly after the knee swelled, but gave 
rise to no great pain or inconvenience, except a slight limping and feeling 
of tiredness ; the swelling slowly increased and became somewhat more pain- 
ful, especially at night, with night startings. We cannot too strongly insist 
upon the fact that tubercular disease of joints may go on for months, steadily 
getting worse, without any pain at all, and with but little impairment of 
mobility ; this so frequently occurs, and yet is so frequently a cause of mis- 
takes, that we desire to emphasize the statement here. At this time the child 
we will suppose comes under observation. The knee is found markedly 
larger in circumference than its fellow, its natural hollows are obliterated, it 
may or may not be slightly hotter than the other, there is slight flexion, and 
usually it cannot be fully extended, any attempt to do so causing pain. 
There is considerable pain on pressure over the inner tuberosity of the tibia, 
and to a less degree over the outer side. The swelling is soft, elastic, and 
pseudo-fluctuating : it may exactly follow the normal outlines of the joint, or 
be more globular, the upper synovial pouch not being thickened ; occasion- 
ally the swelling is almost limited to the upper sac. There is pretty free 
mobility of the joint at this stage, unless an attack of acute inflammation has 
supervened upon the chronic mischief. Such a case left to itself will later on 
become more flexed and less mobile, abscesses will form and burst at the 
sides or front of the joint, the swelling will increase, and the veins over the 
surface may become dilated and full ; the tibia will become subluxated back- 
wards and outwards, and at the same time rotated outwards upon the femur ; 
the limb will become wasted and powerless. In many cases pain increases 
and the child's health suffers, until at last the pain and discharge ; or the 
invasion of other organs by tubercle, wears him out. 

The severity of the symptoms varies greatly : in some instances pain and 
stiffness exist throughout ; in others free, though not usually full, mobility 
and absence of pain may be found during nearly the whole course of the 
disease. 

If a knee joint, such as the one described, is laid open, the synovial 
membrane is found everywhere converted into a thick, pinkish-grey or 
yellowish, semi-transparent material, soft and gelatinous to the touch, but in 
parts tough and elastic ; in parts the grey tissue is streaked with opaque 
fibrous bands, and here and there caseous foci will be found softening and 
breaking down — these are especially common towards the posterior part of 
each femoral condyle. These breaking-down foci do not usually commu- 
nicate with the cavity of the joint itself, which is largely filled up by the thick 
granulation masses, and contains little or no fluid. 

The pulpy tissue grows over the cartilages at first in delicate vascular 
tendrils or films, but afterwards these become thicker and form fleshy pads 
replacing the cartilage at the edge and lying m pits dug out of its surface, so 
that finally only a small central island of healthy cartilage remains in the 
middle of each condyle and each articular surface of the tibia. 

Often granulation sprouts spread beneath the cartilage and, detaching 
it from the bone, give rise to superficial rarefying ostitis, ' subchondral caries,' 
which causes necrosis and separation of the articular cartilages. 

The semilunar cartilages are as it were embedded in the gelatinous tissue, 



Disease of the Knee 615 

and in some far advanced cases can hardly be distinguished ; usually, how- 
ever, they are readily made out. The crucial ligaments are coated over 
with the pulpy tissue, and are often very vascular, with bright streaks of vessels 
running along them ; on scraping away this tissue the ligaments are found to 
have nearly their natural appearance, except that here and there a little 
sprout has forced its way between their fasciculi. The degree of destruction, 
however, of course varies in different cases, and in some the tubercular focus 
is, at first, strictly limited to one patch of synovial membrane. 

The cavity of the joint is often subdivided into loculi by adhesions be- 
tween masses of the granulation tissue. On gouging out one of the granula- 
tion pits in the cartilage, it will be found in some cases not to extend through, 
in others the bone beneath is reached and locally eroded. 

The capsule and lateral ligaments &c. are much thickened, and this 
gives rise to the deceptive sensation of bony thickening so often met with in 
the knee. However much it may appear that there is enlargement of the 
bones in a case of chronic disease of the knee, it is almost perfectly safe to 
say that the thickening is in the soft parts alone, and that there is no new 
bone formation. It is only very rarely that a layer of periosteal new bone is 
found beyond the limits of the capsule. The presence of new bone about a 
chronic tubercular joint is usually a sign of repair and of subsidence of the 
disease ; sometimes, however, it is associated with central bone disease 
(chronic osteomyelitis), never, we think, with progressive synovial disease 
alone. Mr. Watson Cheyne, however, states that microscopically thickening 
of bone trabecular precedes tubercular infiltration in caries of the articular 
ends of bones. 

There is usually more or less atrophy of the bone adjacent to a chronically 
diseased joint. The cancellous tissue is more open in texture, and the com- 
pact tissue thinner than in health. Wasting of the bones, in fact, takes place, 
just as of the muscles and other tissues around the joint. These changes 
are general. When local patches of marked rarefaction are present, that 
part must be considered the seat of actual disease. 

In the great majority, however, of cases of disease of the knee the bone 
is healthy, unless the disease is far advanced ; when this is so, islets of soft 
rarefying bone and carious patches will be found, the latter in their early 
stages being recognised by the yellow and red mottling in the neighbourhood 
of the articular cartilage, with some rarefaction. It is often very difficult to 
be certain of the condition of bone in very early stages of disease : patches 
of various shades of yellow and red are met with in perfectly healthy bono : 
where there is any local rarefaction or opaque yellow deposit disease is 
present. In some instances, however, sequestra of varying si/e arc found — 
most commonly in the femur, less often in the tibia ; usually the necrosis is 
at the back of one or other condyle ; we have, however, found it in the 
middle of the intcrcondyloid notch. Where necrosis does occur the disease 
often tunnels a considerable way through the bone, or rather the disease has 
probably begun in the epiphysial line or epiphysis itself, and extended towards 
the joint. 

As Mr. Howard Marsh has pointed out, a condition of 'quiet strumous 
disease' ma)- exist, leading to a stiff joint without any active stage or suppu- 
ration ; we have seen such joints occasionally, and they are to be distinguished 



616 Diseases of the Joints 

by having a greater amount of solid thickening than occurs in serous syno- 
vitis, but less than in the ordinary tubercular joint. 

Tubercular Disease of the Shoulder is rare in children ; there is hardly 
sufficient evidence to show how often the disease begins in the synovial 
membrane and how often in bone. The swelling forms a globular mass, 
most prominent in front, and stiffness of the joint is usually marked. When 
suppuration occurs the abscesses usually point behind or in front of the del- 
toid, occasionally in the posterior triangle ; no information as to the primary 
lesion can be obtained from the position of the sinuses, since extra-articular 
abscesses due to epiphysitis discharge in the same spots. Disease in the 
epiphysial line may or may not lead to destruction of the joint. In one 
interesting case we removed, as a sequestrum, part of the upper end of the 
diaphysis, including the epiphysial line, and subsequently nearly the whole 
shaft of the humerus ; the inflammation had spread from the periosteum 
to the capsule, and the ligaments became so relaxed that there was a deep 
groove below the acromion, the humerus having dropped away from the 
scapula ; the joint did not suppurate, and all went on well. 

We have only two or three times found it necessary to excise the shoulder 
joint in children ; in all the other cases the disease has subsided, or the case 
has been lost sight of. In one instance, where there was much necrosis, a 
very useful limb resulted with f-inch shortening, and but little wasting, but 
the joint was hardly at all mobile. 

Case. — Disease of Shoulder Joint. Excision. — Lewis H., age 4 years; admitted 
July 19, 1882. Three years ago the left arm was seen to be stiff and painful ; abscesses 
formed about the shoulder and were opened ; no bone removed ; for last eighteen months 
had been discharging a little constantly, and lately the child had lost flesh ; no phthisis in 
family ; other children healthy. On admission, rather pale, but fairly nourished boy ; 
general thickening all round the left shoulder ; a patch of red thinned integument, with 
pus beneath, in front cf the insertion of the deltoid, and a sinus at the posterior border of 
the muscle : the pectoral fold bulged downwards and forwards ; there was pain in move- 
ment. July 26, much discharge, especially on pressure about the axilla; very little 
mobility, even under chloroform, slight power of rotation alone remaining. August 2, 
the upper end of the humerus was excised, together with about an inch of the shaft, by a 
single straight incision at the anterior border of the deltoid ; two loose sequestra weie 
found in an abscess cavity surrounding the head of the humerus ; the joint was entirely 
destroyed ; the glenoid cavity and acromion were roughened ; there was some deposit of 
new bone around the upper part of the shaft of the humerus ; the part removed was not 
entirely necrosed, but there was a large cavity in it ; terebene dressings, hand slung up 
to chest ; some rise of temperature followed. He went on well, but slowly ; at one time 
some bare white bone was seen, but this vascularised subsequently, except a small part 
removed on August 26, and two more small pieces which came away in September. 
Passive movement was begun on September 23, and on the 28th more free movement was 
made under chloroform. He had chicken-pox in October, and was discharged with sinuses 
still open on November 8. Passive movement failed subsequently to give him any great 
amount of mobility. February 1883, he is well and strong, and has good use of the arm, 
but the movement is almost entirely of the scapula ; the limb is not much wasted, and 
there is |-inch shortening. 

Disease of the Elbow Joint arises either as a primary synovitis or about 
equally often as disease of bone ; in the latter case the olecranon or one 
of the condyles, most often the outer, is first attacked. Well-marked cheesy 
masses are often found in one or other condyle, but any extensive disease of 



Disease of the Wrist 



617 



the radius is very rare. Swelling extends all round the joint, but usually 
appears first over the radio-humeral line at the back of the joint. Later the 
front of the joint becomes swollen : this is sometimes due to glandular en- 
largement, comparable to the swelling of the inguinal and iliac glands in hip 
disease ; in other cases the supra-condyloid gland suppurates. When the 
olecranon is the seat of the primary lesion the sinus is usually over it and 
leads directly, or nearly so, down upon it. 

In old neglected cases, the number of sinuses is sometimes considerable, 
and the soft parts are undermined and much destroyed by pulpy infiltration. 
The joint is kept slightly flexed, and there is usually much muscular wast- 
ing. Occasionally we think the disease begins in the olecranon bursa, which 
is so common a starting-point for mischief in older patients ; this bursa is 
sometimes chronically enlarged in children. Stiffness is an early and marked 
feature of disease of this complex joint, though the mobility of the fingers 
is good, even if there is much infiltration of the muscular attachments about 
the elbow. 



Case. — Joseph L. D., age 3 years 11 months; admitted January 27, 1882. Left 
•elbow injured by a fall in April 1881 ; had been swollen ever since. On admission, 
healthy -looking child ; the left elbow was flexed and the hand semi-pronated ; very little 
mobility ; two sinuses at the upper and back part of the joint led clown to rough bone ; a 
little tenderness, but no pain ; general swelling all round the joint. February 2, the joint 
was excised ; disease primarily synovial ; cartilage diseased, especially on head of radius ; 
•operation not antiseptic ; the limb was put 
upon an angular splint. On the 13th pas- 
sive motion was begun. On March 1 passive 
movement could be carried through the full 
range in all directions, and there was a little 
power of active movement ; the wound was 
nearly healed ; discharged. October, 1882, 
at out-patients' ; elbow quite healed ; had 
almost perfect range of mobility in every 
way, and the arm was strong ; he could lift ■ 
a chair with it. 



The Wrist Joint is perhaps even 
more rarely affected with tuberculosis 
than the shoulder, but in children we 
have on three or four occasions had to 
excise the joint ; in all, the wrist joint 
itself, as well as the whole carpus, 
was disorganised, the disease having 
spread among the synovial sacs. In 
one instance the mischief began in the 
base of the second metacarpal bone, 
in the others the starting-point was apparen 
an excellent result followed, the whole ( 
metacarpal hours, and the lower ends o( the radius and ulna having been 
removed by a single median dorsal incision between the tendons o( the 
extensor indicis ami the extensor secundi internodii pollicis : no tendon 
was cut through, though necessarily those attached to the pans removed 
were stripped back. In both o( these cases a nearly perfectly mobil< 





:ulir Disease of th 



y synovial. In two of the cases 
the carpus, the bases o( the 



6i8 Diseases of tJie Joints 

was obtained with almost full mobility at the metacarpophalangeal articula- 
tion — the point of greatest difficulty in disease of the wrist. 

Case. — Disease of Wrist Joint. — Annie E. , age 6 years. Admitted March 25, 1885. 
History unimportant. No cause known for swelling of left wrist, which began six months 
before admission ; much pain ; poulticed for three months. On admission, a strumous- 
looking child ; on palmar aspect of left radius at lcwer end is a sinus ; much thickening 
round wrist ; fluctuation in front of carpus ; movements of fingers perfect ; those at carpal 
joints absent. April 16, whole carpus except pisiform bone removed by longitudinal inci- 
sion on dorsum ; some bones broken clown and unrecognisable ; cavity scraped, and drained 
through palmar sinus. May 1, wound has progressed fairly and is now healing. 15th, 
sent home ; tube still in wound ; arm on splint ; result very good ; a strong and mobile 
hand (fig. 124). 

One patient remains sound ; the other, after keeping well for along time, 
developed tubercular teno-synovitis, which will probably cause some loss of 
movement. In the third case the carpus alone was taken away, with an 
even better result. The operation mentioned is practically Langenbeck's ; 
it is much simpler than Lister's method, and we think much superior to it : 
the bones which are not already softened and destroyed shell out easily 
from the pulpy material in which they are embedded. The position of the 
sinuses in carpal disease is inconstant, but the general appearance is shown 
in fig. 124. 

Chronic Tubercular Disease of the Ankle is much less frequent than 
that of the knee ; but in four years we had 43 cases of disease of the ankle 
or tarsus admitted as in-patients at the Children's Hospital. Of these, ex- 
cluding disease of the os calcis, most of the cases were probably primarily 
synovial, but in the tarsus extension of disease around the small bones so 
interferes with their nutrition, and so readily spreads to their interior, that in 
late cases there is always more or less destruction of bone. We can only 
recollect one, or perhaps two instances of primary necrosis of the astragalus 
setting up disease of the ankle joint ; but it is much more common to find 
mischief spreading from the lower epiphysis of the tibia to the joint. 

Except the posterior calcaneo-astragaloid joint, the anterior calcaneo- 
astragaloid and its continuation, the astragaloscaphoid joints are, perhaps, 
the most commonly affected of the tarsal articulations ; but the common sac 
or any of the tarsal joints may be attacked by disease, which then spreads 
from one joint to another. Calcaneo-astragaloid disease is very frequently 
the result of necrosis of the os calcis, and it not rarely extends upwards to 
the ankle joint itself. 

Disease of the ankle joint is marked by swelling at the back of the joint, 
obliterating the hollows on each side of the tendo Achillis, and then spread- 
ing round and below each malleolus, especially the inner (fig. 125) ; the 
front of the joint also becomes swollen, and acquires a peculiar flatness or 
squareness of outline as a result of loss of salience of the extensor tendons. 
The foot is usually kept with the toes pointed, at other times it is dorsi- 
fiexed ; the leg rapidly wastes ; later, sinuses appear, usually above or behind 
the malleoli. It must be remembered that disease often extends from the 
joint into the sheaths of the neighbouring tendons, and in such cases suppu- 
ration or swelling may track up the leg or along the foot for a considerable 
distance ; the general conditions do not differ from those met with in the 



Acute Synovitis 



619 



Jr 



knee. In disease of the tarsal joints the foot is swollen in the position cor- 
responding to the affected articulation, and movement of the particular joints 
may be painful. This is not, however, a very trustworthy symptom in tuber- 
cular disease, though of much value in acute inflammation. When the 
common sac is involved the foot assumes a bulbous look, with the toes pointed 
and pressed closely against one another. The disease often spreads beneath 
the extensor or along the plantar tendons, and gives rise to widespread 
mischief in the soft parts, so that a 

sinus by no means always indicates ^/' 

disease of the nearest joint. The arch 
of the foot is seldom lost, in consequence 
of the resistance of the rigid structures in 
the sole of the foot. With two exceptions, 
the disease is usually primarily synovial : 
one is that already mentioned of caries 
or necrosis of the os calcis, which often 
extends to the calcaneo-astragaloid joints ; 
and the other, that it is common for dis- 
ease of the first metatarsal bone to extend 
backwards to the joint between it and the 
internal cuneiform. 

It is sometimes difficult to be sure 
whether an abscess on the dorsum of the 
foot — the most common situation for 
pointing in tarsal disease — is connected 
with the joints or is merely peri-articular : 
in some cases pain on pressure or move- 
ment of individual joints, localised by 
pressing back towards the ankle individual 
toes in turn, in others swelling over some particular joint or in the sole, 
will indicate a deep lesion ; but often exploration is required before a certain 
conclusion can be arrived at. 

Acute simple Serous or Suppurative Synovitis is uncommon in child- 
hood except as the result of injury or rheumatism ; any joint may be affected, 
and the symptoms in no way differ from those seen in adults. There is 
swelling, which, being due to distension of the synovial sac, follows its out- 
lines ; heat and pain, with immobility and some constitutional disturbance, 
are also present. The inflammation commonly subsides readily by treat- 
ment with splints and ice or evaporating lotions, and leaves no ill results. 
In some cases, however, usually in unhealthy children, or where there has been 
a wound of the joint, suppuration occurs ; all the symptoms are then greatly 
aggravated, any movement is exceedingly painful, and the temperature may 
rise to io3°-io4°. 

The acuteness and severity of the symptoms vary much in these cases : 
in one instance the hip joint suppurated, nearly the whole thigh was occu- 
pied by a large abscess, the head o( the femur was partially destroyed, and 
the mischief extended to the knee joint, which also suppurated : both joints 
were incised, but the child sank and died. Pus was iound in the knee, 
with superficial erosion of cartilages : the synovial membrane was thick and 



Fig. 125. — Tubercular Disease of the 
Ankle Joint. 



620 Diseases of the Joints 

hyperaemic, the thigh was infiltrated with sero-purulent fluid, and the 
acetabulum was granulation-lined. 

In other cases there is a thick 'mucous' discharge and the cartilages are 
not destroyed : in these cases incision generally results in recovery with a 
mobile joint. This form of disease most commonly occurs in children under 
two years of age, and is met with in the knee — less often in the shoulder, 
elbow, hip, or foot. Somewhat like the above-mentioned catarrhal inflam- 
mation of joints, described by Volknlann, appears to be a form of painless 
purulent exudation, not connected with pyaemia or epiphysitis, which has 
been described by Atkin, of Sheffield. 1 

Pyaemic Joint Disease is not rare in children, and may run an acute or 
chronic course. The articular lesions may be the only evidence of pyaemia, 
or they may occur in conjunction with bone or visceral abscesses. Both 
forms of disease are exceedingly dangerous, though neither by any means 
always fatal. We have had a case under our care of a boy aged 3| years, 
who had pneumonia after measles, and subsequently suppuration in one 
shoulder and one knee, with effusion into one of his ankles, and double em- 
pyema, together with abscesses in other parts ; this child recovered perfectly, 
with a mobile knee, though with a somewhat stiff shoulder. Effusion into a 
joint in pyaemia is not always purulent, nor does the presence of pus in a 
joint or elsewhere always demand incision and drainage ; the effusion may 
be absorbed, or, after aspiration, may not recur, and on examination the 
articular cartilage may be found quite smooth and healthy, or only somewhat 
yellow and opaque. In other cases, however, the cartilage becomes necrotic, 
•or it may rapidly melt away entirely or in patches, leaving the articular 
lamina of bone smooth and bare ; this is perhaps the most typical condition 
of acute pyaemia. 

Exanthematous Synovitis, or that form of joint disease which occurs 
in connection with the specific fevers, has already been alluded to in discuss- 
ing those affections, and scarlatinal synovitis or rheumatism has been fully 
•described (p. 264). A second variety occurs generally, but not always, later 
in the course of the fever, and usually in connection with severe throat lesions. 
The affected joint suppurates and becomes disorganised ; this is clearly a 
pyaemic condition. 2 It must also be remembered that the exanthems are 
sometimes a determining cause of the appearance of a tubercular lesion. 
Typhoid synovitis is rare, and is said to be almost limited to the hip joint ; 
we have, however, seen the knee attacked, and, as Gibney has pointed out, 
the spine may be affected. Synovitis, probably pyaemic, occurs as a rare 
complication of diphtheria. An exanthem such as scarlet fever or measles, 
occurring in the course of a joint disease, usually gives rise to suppuration 
and rapid destruction of the joint ; in some cases, however, it appears that, 
as in the case of erysipelas, the more active inflammation does good by 
causing melting away or absorption of the chronic inflammatory material. 

Chronic Rheumatic Arthritis occurs occasionally in children, both in its 

1 Brit. Med. Jour. July 11, 1885. 

2 Chains of micrococci have been found in the pus from such joints by Heubner and 
Bahrdt, and a similar joint affection has been caused by inoculation with cultivations from 
tonsillar exudation by Loffler ; vide Berlin. Klin. Woch. November 3, 1884, or abstract 
by Dr. Ashby in Med. Chron.' December 1884. 



Syphilitic Synovitis 



621 



polyarticular (nodular) and monarticular forms, as pointed out by Charcot 
and others, and we have once or twice seen it. It must be remembered 
that such cases may become tuberculous, and we have seen a joint which 
had the characters of chronic rheumatic arthritis well marked, which sub- 
sequently became an ordinary pulpy knee, just as occurs in adults ; the two 
conditions may be seen co-existing in one joint. 

Case. — Chronic Rheumatic Arthritis. — Mary Jane E. , age 13 years; admitted Feb- 
ruary 25, 1884. No rheumatic or gouty history. Duration since August 1882, when she 
had pains in her shoulders, which subsided in a week. Nine months ago had pain in left 
hip, which lasted four months ; then the left knee was attacked ; both were swollen ; 
no other joint affected ; pains worse in wet weather; not increased in bed ; sweats a good 
deal at nights ; urine often contains red lithates. On admission, well nourished; slight 
eczema of face ; heart sounds normal ; right knee a little swollen ; no crackling or thicken- 
ing ; no osteophytes. Left knee, thickened synovial fringes ; well-marked crackling ; edges 
of both condyles distinctly lipped. Her condition improved with blistering and iodide of 
potassium, and she was sent out on March 15. 

Syphilitic Synovitis is occasionally met with ; we have, however, only 
seen a few cases of pure synovitis in the first few months of life in congeni- 




al 

Fig. 1 s6. Congenital Syphilitic Syi 

tally syphilitic children ; the most common condition is syphilitic telostitis. 
A subacute recurrent syphilitic synovitis occurring in older children is met 



622 Diseases of the Jo nits 

with ; it sometimes rapidly subsides under antisyphilitic treatment, as in the 
following instance ; but this is not always the case— it is sometimes rather 
intractable. 

Case.- Syphilitic Synovitis of A' nee. — Jane B. , age 8 years 3 months ; admitted Octo- 
ber 31, 1882. A history of syphilis in the brothers and sisters, of whom there have been 
twelve, seven being dead ; patient herself had always been hearty ; two years ago the left 
knee swelled without known cause, but recovered completely in fourteen days ; the eyes 
bad been bad since May 1882 ; the right eye was first affected, and the left was only 
attacked three weeks ago ; has not had much photophobia ; the left knee began to swell 
on October 29 ; she had a good deal of pain in it. On admission, the left knee was much 
distended with fluid, and was slightly hotter than the right ; she had well-marked inter- 
stitial keratitis, which was, however, subsiding ; facial aspect and teeth also characteristic ; 
no other signs marked. Under hyd. c. cret. and pot. iod., together with a back splint for 
the knee, all the swelling rapidly subsided, the eyes improved, and she was discharged, 
nearly well, on November 21. 

Clutton has noticed the occurrence of symmetrical synovitis of the knee 
in congenital syphilis, and Gutterbock 1 other cases of asymmetrical effusion ; 
we have seen the same thing associated with periostitis of both tibiae. Car- 
rington and Lane record a case of suppurative synovitis of the hip, knee, 
shoulder, and both elbows in a child with congenital syphilis ; there was 
rickets also present, but no epiphysitis.' 2 

The best treatment of these cases is the administration of iodide of 
potassium internally with hydrarg. c. creta, while mercury ointment should 
be rubbed into the part affected ; if there is much pain, blisters will sometimes 
give relief. Gonorrheal rheumatism is sometimes met with in children 
in association with vaginitis or ophthalmia neonatorum, as pointed out by 
Clement Lucas and others. We have seen an infant a few weeks old in 
which a stiff flexed wrist remained as the result of what was described as 
4 erysipelas of the hand.' The swelling of the hand was noticed on the 
evening of the day the child was born, and it had also purulent ophthalmia. 

Acute suppurative Arthritis of Infants, first described by T. Smith of 
St. Bartholomew's, 3 is a remarkably well-defined affection of fairly frequent 
occurrence. It is limited usually to children under a year old, though we 
have occasionally seen it in older children, the eldest being nearly two years 
of age. Pathologically the disease is an acute epiphysitis leading to rapid 
destruction of the ossifying centre of the bone it attacks, with perforation into 
and disorganisation of the adjacent joint. In one instance the epiphysial 
nucleus of the head of the femur was found lying loose in an abscess cavity, 
or rather in a sinus leading from the joint. A large number of the infants so 
attacked die of pyaemia. The hip is the joint most frequently affected, the 
knee standing next. Of ten cases of our own the hip was involved in eight 
instances — six times alone ; in one other case the knee was involved by direct 
extension, and in another the wrist, shoulder, and hip were implicated. In 
two instances the disease followed whooping cough, in one it came on after 
an injury, and in one some evidence of the onset of the disease in utero was 
obtained. We have adopted Mr. Smith's view that the lesion is primarily 

1 Rev. Mens, des Mai. de I ' Enfa.7ice. 

2 Brit. Med. Jour. January 1S85. Path. Soc. Trans. 1885. 

3 Morrant Baker, John Poland, and one of the present writers have also contributed to 
the literature of the subject. 



Acitte Suppurative Arthritis 623 

epiphysial ; and it is so certainly in the majority of cases, but in one or two 
we have not found evidence of anything- more than synovial disease ; these 
would perhaps rather correspond to Volkmann's ' catarrhal synovitis ; ' and, on 
the other hand, we have met with several cases in which the abscess pointed 
outside the joint, the cavity of which was not involved. In one instance the 
lesions were secondary to a cervical abscess, and there was epiphysitis of one 
shoulder and a peri-articular abscess of the other, so that sometimes at least 
the presence of an abscess about a joint in an infant is not due to an epiphy- 
sitis, and sometimes it is not an arthritis. Battle believes it to be usually an 
affection of the end of the diaphysis : primarily. It is often difficult to make 
out the connection between the abscess and the joint, but with care it may 
be found in most cases. The severity of the disease varies considerably ; in 
some instances the mischief goes on for two or three months, in others it is 
fatal in a few days. The characteristic features are the age of the child ; 
the existence of great swelling round the affected joint, often involving nearly 
the whole limb, and not uncommonly 'flying about' — i.e. one limb becomes 
swollen and then subsides, then the swelling appears in one of the other 
limbs, and finally the disease becomes localised in one joint only, leaving the 
parts first attacked uninjured. This curious feature of the disease perhaps 
indicates its relation to pyaemia. In acute cases there is much fever, but 
there may be little rise of temperature in the more chronic ones. We have 
seen a case in which tubercle was apparently engrafted on a case of ' acute 
suppurative arthritis ' of the hip. 

The symptoms and course of the disease point to thrombosis, extending 
from the vascular cancellous tissue, or to embolism, but we have not verified 
th'S condition post mortem. The size of the abscesses is sometimes remark- 
able ; in one case the whole thigh, from the hip to the knee, was a bag of 
pus, both joints being involved. 

These children are generally much prostrated and often very anaemic, 
worn out by pain and rapid outpouring of pus. 

Treatment consists in early and free incision into the abscess, opening 
the joint if it is swollen, and keeping it well drained. Stimulants and abun- 
dant nourishment must be given. It is not necessary to put the limb in a 
splint in infants, but it is a good plan to tie it up in a pillow so as to keep it 
steady ; there is little or no fear of a stiff joint. Probably half the acute cases 
die. If recovery takes place, the limb is usually shorter and weaker than the 
other, but there may be a practically perfect recovery, and there is generally 
good mobility. We have several times seen older children with weak limbs 
clearly the result of this disease in infancy. Arrest of growth is less likely 
to occur where the hip is involved than the knee. The two following are 
fairly typical cases. 

(.' \sk. — ' Acute Suppurative Arthritis ' of Hip. — Alfred YV. , age 9 months ; admitted 
May 3, 1884. History good; never very strong'; no known cause; swelling about hip 
one month ago. On admission, pale, l>ut not thin ; abscess round right hip ; grating 
in joint. Incision, head of bone gone. 5th, takes food well ; much discharge : temperature 
subnormal. Did moderately, but on 15th still looked pale and ill. Sent home on 94th 
with wound superficial. Subsequently fresh suppuration occurred, but after a 
struggle the limb became sound and well, with good mobility and little shortening. 



Brit. Med. your. May 9, 189] 



624 Diseases of the Joints 

CASE. — 'Acute Suppurative Arthritis' of Knee. — Mary H., age 9 months; ad- 
mitted March 21, 1885. Family history good; child first noticed to be feverish and 
restless nine days ago ; the knee then swelled rapidly, and was very tender ; the swelling 
is now less than it was a few days ago. On admission, a well-nourished child ; right knee 
swollen, hot, tense, and shining ; fluctuation felt readily ; girth 10 in. as compared with 
yh in. on the left side ; temperature 97°. Joint freely incised on outer side, and a quantity of 
pus escaped. 23rd, swelling gone down ; a fair amount of discharge ; takes food well, and 
sleeps well ; temperature 101 . April 1, pus tracking upwards and inwards ; a larger tube 
inserted. 13th, swelling less; doing well. May 2, all swelling gone; tube removed, 
nth, wound healed ; all well. 

Acute Tubercular Synovitis is not a very common affection ; it does, 
however, occur, and rapidly goes on to suppuration in quite young children. 
The most typical instance we have seen was in a baby ten months old, in 
whom suppuration of the ankle occurred a week or two after a scald over the 
joint. On incision a few drams of curdy pus escaped. A week later the 
child died of pneumonia and was found to have generalised tuberculosis ; 
the lungs, liver, kidneys, spleen, and brain were all affected. Here, from the 
condition of the tubercular masses in the brain, it was clear that tuberculosis 
existed at the time of the injury to the skin over the ankle, and the joint 
subsequently became tuberculous. The case serves to illustrate the fact that 
in the first year or two of life suppuration occurs as a result of inflammation 
more readily than in older children. Acute tubercular disease also some- 
times follows strains or fractures in the neighbourhood of joints ; thus we 
have seen advanced pulpy disease of the elbow, in a girl of eight years, nine 
days after an injury which loosened the epiphysis of the inner condyle and 
trochlea of the humerus. The following case is also noteworthy as an illus- 
tration of the occasionally acute onset of the disease : 

Case. — Acute Pulpy Knee.— Harry A., age 3 years 9 months; admitted January 4, 
1885. No tubercular history ; had measles at two years of age, followed by whooping 
cough ; disease of knee first noticed fourteen days ago ; no cause known. On admission, 
stout, well-nourished boy ; right knee is much enlarged, joint hollows obliterated ; swelling 
elastic; no distinct fluctuation ; movements very limited and painful ; right knee iof in. , 
left knee 9 in. ; extension applied. 17th, knee straight ; no night pain ; general condition 
good. 21st, as some fluid was thought to be present, the knee was aspirated, and two 
drams of sero-pus drawn off. 25th, temperature normal ; general health good, but there 
is still fluid in the joint. February 4, the knee was enlarged to its original size, a Thomas's 
splint was applied, and he was sent home. Readmitted April 29. He wore the splint up 
to readmission, and has been doing fairly well till lately. On admission, the swelling has 
increased to n in. and extends some distance up the thigh ; the veins are full, and the 
skin tense and shining ; the patella floats ; free incisions were made into the joint : a 
large quantity of turbid serum escaped from the incision on the outer side, while from 
the inner one, which was somewhat lower down, pus flowed ; operation antiseptic ; 
drainage as usual ; the wound was dressed on May 2 and 12, when there was not much 
discharge and the knee was quiet ; temperature never above 99 -4°. 26th, still a good deal 
of swelling ; some thick, cheesy pus squeezed out ; the knee did not improve much, and 
on June 29 he was taken home by his friends. July 6, readmitted, knee as on discharge. 
18th, temperature 102° ; some retention of pus on inner side of thigh above knee. 23rd, 
excision of joint ; much thick pulpy material, cartilage eroded, but surface of tibia healthy, 
except a small portion at the inner margin, which was gouged away ; surface of femur 
bare and rough, and bone soft and showed several points of pus ; when gouged the bone 
was quite soft, yellow and infiltrated with pus ; this was removed, leaving a cavity h in. 
long and | in. deep in the inner condyle ; the bone surface and the upper synovial cavity 
were cauterised with the thermo-cautery, dusted with iodoform, and the limb was put up 



Treatment of Acute Tubercular Synovitis 625 

m a Howse's splint ; wood-wool dressing ; on section of the part of the femur remov.-d 
a yellow caseous mass was found surrounded by soft bone ; there was much shock for 
some hours, which was treated by opium, warmth, and alcohol ; did fairly well, and tem- 
perature was never above ioo° till 29th, when the knee was dressed for the first time, the 
temperature having run up suddenly to 104 (?) ; wound looked well and was quite sweet ; 
pads of wood wool uniformly soaked ; temperature fell and was not above ioi° after 
30th. August 3, free discharge, doing well, but splint soiled ; it was removed, and replaced 
next day ; union seemed firm. 8th, tubes removed ; there was afterwards some trouble 
with the splints, which needed changing, and the wound on the 14th was no longer aseptic ; 
the tibia became displaced somewhat backwards and some fresh suppuration followed ; this 
was combated by making him lie on his face for half the day ; he slowly improved, and on 
October 16 the wounds were nearly healed, and he was sent to Convalescent Hospital. 
April 3, 1886, one sinus, the rest of the wound well shrunk ; not yet firm, but in good 
position ; fat and well. 

The treatment of the various joint affections can only be briefly given 
here ; it is impossible to mention all the applications and apparatus that 
have been devised. In acute nonsuppurative joint affections of the upper 
limb, in the case of the shoulder, it is sufficient to strap the. arm to the side, 
or, if the child is very young, to bind the limb with a flannel bandage across 
the chest ; lead lotion in infancy and an ice bag in older children is the only 
further application required. For the elbow nothing is better than a common 
inside or outside angular splint, which must reach from the axilla to beyond 
the end of the fingers ; all short splints, leaving the wrist and fingers free, are 
obviously insufficient. For the wrist a straight palmar or dorsal splint reaching 
from the elbow to beyond the finger tips should be applied. 

For the hip a Bryant's or Thomas's splint should be put on, or, in their 
absence, a long Liston's splint does very well. For the knee and ankle the 
ordinary back splint with a foot-piece should be used, taking care that when 
the knee is the part injured the splint reaches well up to the buttock. A 
Thomas's knee splint answers excellently for all stages of knee-joint disease, 
but the child must of course be kept in bed for acute affections of the joints 
of the lower limb. 

When suppuration occurs free incisions should be made into the joint, and 
drainage tubes inserted ; where there is no previous opening, and the wounds 
are aseptic, washing out of the joint may. be employed, and the wound then 
closed by sutures or the cavity may be drained, choosing a dependent posi- 
tion for the incisions, and avoiding the dangerous anatomical area of each 
joint. In sub-acute cases, with sero-purulent fluid or even pus in the joint, 
aspiration should be tried once or twice before free incisions are made ; but 
the joint must not be allowed to become distended with fluid, since this 
frequently leads to subsequent ligamentous weakness. 

In chronic non-purulejit effusion, and in cases where a simple synovitis 
has left thickening behind, elastic pressure by a Martin's bandage lightly 
applied, or by common bandages applied over a thick layer of absorbent 
wool, does good service. Friction is often useful, and blisters frequently 
relieve pain and promote absorption. Care must be taken not to be misled 
by the presence of adhesions remaining after subsidence of disease into 
thinking that progressive mischief exists. A joint that has been acutely or 
subacutely inflamed, and after a week or two of treatment remains stiff, a 
little swollen, cold, and tender on pressure over one or two spins, with intense 



626 Diseases of the Joints 

pain at perhaps one spot on any movement beyo?id a certain point, though 
movement may be free up to that point, is the seat of adhesions, and requires 
breaking down of these bands under chloroform. In such cases inquiry 
should always be made to ascertain that there is no evidence of any tubercular 
taint before moving the joint. After breaking down adhesions the limb 
should be kept quiet for twenty-four hours and effusion prevented by pressure 
or cold ; and then, if all is quiet, both active and passive movement should 
be begun. While recognising the effect of adhesions in and about joints, it is 
well to remember that it is much less common to meet with cases of this 
kind among children than among adults or adolescents ; probably because 
the restless activity of childhood prevents the joint from being kept still after 
the acute and painful stage is over. 

When a joint has suppurated no premature attempts at procuring mobility 
should be made. As soon as the joint has been soundly healed for a 
week or two all apparatus should be left off, and the child allowed to try for 
itself — left, in fact, to do as it likes, in reason — it will seldom do too much. 
If after a few days no progress in mobility is being made, chloroform should 
be given and the joint carefully examined. It is generally possible to make 
out whether the adhesions are few. and cordlike, or general ; in the latter 
case a permanently stiff joint will almost certainly result, in the former the 
adhesions should be at once broken down. Where a stiff joint is arranged 
for, the limb must for many months, often years, be provided with a splint to 
keep it in the desired position. Children's joints are very slow to anchylose. 
We have no great belief in inunction with Scott's ointment or oleate of 
mercury, and painting with tincture of iodine, as modes of treating chronic 
joint lesions, but pressure and friction are invaluable when acute mischief 
has subsided. 

In all cases of synovial tuberculosis in the early pre-suppurative stages 
but one form of local treatment is, we believe, of much value — absolute 
fixation, with or without pressure. Where there is acute pain or a subacute 
attack in the course of chronic disease counter-irritants in the shape of 
blisters or the actual cautery are useful to relieve the pain, but we do not 
think they do any great good otherwise. We have tried and given up 
injections- of iodine and carbolic acid into the pulpy tissue, and we cannot 
say we think Scott's dressing is of any great use, except as a means of 
pressure. For the upper extremity the plans mentioned for acute disease, 
combined with elastic compression, are all that is required ; for the elbow 
and wrist the splint may be made permanent by fixing it on with plaster of 
Paris, or substituting light iron strips in the plaster for the wooden splint, 
or a poroplastic splint may be used. It is common to see figures of 
appliances for disease of the elbow and wrist in which the fingers are left 
free and can be moved ; this seems to us opposed to all principles of keeping 
the joints at rest, inasmuch as every movement of the fingers must necessarily 
disturb both elbow and wrist joints. The joints of the lower extremity must 
be considered more in detail. 

Treatment of Tuberculous Disease of the Knee Joint. — In early 
stages, where there is no dislocation and little flexion of the knee, the limb 
should be fixed upon a back splint with a foot-piece, and as long as the 
symptoms are acute the child should be kept in bed. If there is much 



Evasion 627 

flexion and pain the limb should be straightened gently under chloroform, 
and a splint then applied with an ice bag over the knee for the first twenty- 
four hours ; where there is flexion, but not much pain, an extension should 
be put on by a weight fixed with strapping below the knee,' or a Macintyre's 
splint may be used — we prefer the weight. As soon as the acute symptoms 
have passed off and the limb is nearly straight — it need not be quite so — a 
Thomas's knee splint with patten and crutches should be provided, and the 
child allowed to get about ; if there is much thickening, elastic pressure 
should be employed at the same time. Where the Thomas's splint cannot be 
obtained, or the friends cannot be trusted to look after the splint, or the child 
is too young to use crutches, a plaster of Paris casing should be put on, 
strengthened by the iron strips, as shown in fig. 130. As Mr. Paul of Liverpool 
has suggested, it is a good plan to cover the metal with rubber tubing. The 
child, if it is old enough, may get about with patten and crutches after the 
plaster of Paris is applied. Children under four years of age cannot usually 
be trusted to use crutches, and must be kept off their feet and taken out of 
doors in a perambulator or carriage. Cod liver oil and iron, careful dieting, 
and fresh, above all sea air — the great medicine for tuberculous bones and 
joints — should be the general treatment where possible. As long as there 
is no suppuration a fair trial should be given to the plan described ; it is 
simple, and we know nothing better. There must be no taking off splints 
for washing or to see how the joint is getting on — one movement of a joint 
may undo weeks of rest ; leather and lace-up splints are for this reason not 
so good for hospital patients as plaster of Paris. Where the nurse can be 
trusted not to play pranks with the joint, such as allowing the child to bend 
it, or stand upon the limb, washing is a luxury that may be occasionally 
indulged in, but fixation comes first. If in spite of this treatment the joint 
gets worse, operation is necessary ; but in the case of the knee a very large 
proportion of patients will get better, and this because the disease is mainly 
synovial. 

When a joint such as the knee, in spite of efficient treatment for two or 
three months, steadily gets worse, pain and swelling increase, and the child's 
health begins to suffer, more active means must be taken, and these will 
become necessary much sooner in acute than in chronic cases. If the pulpy 
material is rapidly breaking clown, and suppurating, and yet the child's health 
is keeping good, success is sometimes obtained by fixing the limb on an 
interrupted splint, or better in plaster of Paris, and then opening and 
carefully draining the abscesses, taking care, if the whole joint cavity is 
suppurating, to drain at the back of the joint or at the lowest point of the 
abscess sac if the suppuration is localised. By this means a certain number 
of these children will do well and acquire sound, straight, and in some 
instances movable limbs. The plan is, however, only exceptionally appli- 
cable. If there is no suppuration, but the pulpy swelling increases, the besl 
mode of treatment is Erasion. 

Erasion, or, as it is now sometimes called, arthrectomy, consists in the case of the 
knee in opening tin- joint freely by a semilunar incision, just as in the ordinary mode 



1 One pound of weight (ov each year of the child's age up to six is a g 

ale. 



628 Diseases of the Joints 

of excising the knee ; the skin is reflected and the capsule removed on each side of the 
patella and patellar ligament, or, better, the patella is sawn across and the fragments 
turned upwards and downwards ; if necessary, free vertical incisions must be made to 
reach as high as the upper limit of the synovial pouches. It is well not to dissect up the 
skin from the underlying tissue more than can be helped, as the pressure of the dressing 
which should be firmly applied sometimes interferes with the circulation in the edges of 
the wound and delays union. Next, every particle of pulpy granulation tissue is carefully 
cut away with scalpel or scissors ; all the infiltrated capsule and the semilunar cartilages 
are removed and the articular cartilage scraped quite clean, any granulation tissue being 
carefully picked out from pits in the cartilage, and, if necessary, any foci of disease in the 
bone gouged away. This process must be most thorough, and extreme flexion of the limb 
is required to fully expose and clean the back part of the joint ; the crucial ligaments are 
scraped, but if sound preserved, the lateral ligaments are divided. The upper synovial 
sac must be thoroughly cleaned. The most difficult part of the operation is getting away 
the posterior part of the semilunar cartilages and the synovial membrane at the back of 
the joint. After thoroughly removing all pulpy tissue it is a good plan to apply the 
actual cautery to any doubtful spots. The process is a tedious one, often lasting one and 
a half or two hours, including the subsequent putting up in a splint. As soon as all 
bleeding has been stopped the limb is fixed on an excision splint and dressed in the 
usual method, antiseptically. Drainage if used should be at the back of the joint on 
each side, the tubes being carried through openings made behind the joint, but in recent 
years we have used no drainage and closed the wound entirely. When this is done it is 
important to arrest all bleeding as perfectly as possible. Usually healing throughout by 
primary union is obtained. We prefer to Esmarch the limb, or at least put on an elastic 
tourniquet before beginning the operation. For a series of cases vide Med. Chron. 
vol. ii. 1885. We introduced the operation in its complete form in January 1881, and 
the first case was that recorded and figured below. Mr. Greig Smith of Bristol had, 
however, he tells us, performed the same operation on an elbow in the previous year, but 
the case was not published until after our first case was recorded. There is, however, we 
believe, no doubt that Mr. Greig Smith was actually the first surgeon to perform erasion, 
though our case was the first published and his was unknown to us till long afterwards. 
We desire to give him full credit for his work. 

Case, — Lizzie N., age 13 years 9 months ; old pulpy disease ; joint erased, all syno- 
vial membrane, much of capsule, semilunar cartilages, and a largish patch of carious bone 
removed, as well as a good deal of articular cartilage scraped away ; result, a perfectiy 
movable, sound, painless joint, used as freely as the other ; ligamentum patellae not 
divided. She was under observation for nearly four years after the operation, and, except 
that she was liable to occasional serous effusion into both knees as a result of overwork, 
she remained well. The knee operated on differs little from the other except for the 
presence of the scar across it. In July 1889 this patient was again seen, and the knee 
remained perfectly sound and mobile. 

Erasion, we think, is applicable to cases of fairly early disease which 
have resisted efficient treatment by splints, &c. Though in the case recorded 
we obtained a freely movable joint, we have never had such a perfect result 
since, nor do we think it wise to try for mobility, except in a few instances 
where the wound heals at once, and the adhesions are few. Erasion, if it 
fails, leaves the limb still fit for excision ; where it succeeds, the limb is as 
sound as after excision, but without shortening. 

The more we see of these cases, the more we feel sure that erasion is the 
proper operation, and that excision is hardly ever required, while the 
result is far better from erasion than excision. We prefer erasion, as above 
described, for the knee, but the general rules of treatment must, of course, 
vary with the particular joints, stability and absence of shortening being 
the cardinal points for the lower limb, mobility for the upper. Mere 



E xxi si on 



629 



scraping through sinuses is of but little use, though if fistulas exist they 
should be well cleared out. 1 Since the case above reported was operated on, 
many other ' arthrectomies' have been performed, and, on the whole, with 
very good results. 

Should it be decided that the case is too far advanced for erasion, ex- 
cision of the joint should be performed. Of several plans that we have tried 
we now employ most commonly the transpatellar operation. This operation 
was first employed by Volkmann, but was introduced to this country by 
Golding-Bird ; it is an admirable method, and, we think, far the best that 
has been devised. 



\\ 





Fig. 127. Fig. 128. 

Show the condition of Lizzie N. after operation, and the free mobility of the joint. 

A short anterior flap of skin is turned upwards by a curved incision running with 
its convexity downwards from one condyle across the apex of the patella to the other 
condyle ; the patella is then cut through with scalpel or saw, according to the degree of 
ossification present ; the lateral attachments are divided and the fragments turned upwards 
and downwards. The lateral ligaments and capsule are freely divided, the bone surfaces 
cleared, and a thin section taken from the tibia with a Butcher's or amputating saw, care 
being taken only just to open up the cancellous tissue and not to trench upon the epi- 
physial line. A section is then made through the condyles of the lemur, exactly at right 
angles with the long axis of the limb, so that when femur and tibia are brought together 
the limb is straight. It is important to remember that in the femur the epiphysial line is 
usually said to correspond with the upper border of the articular cartilage, or with the 
level of the adductor tubercle; it may, however, as we have found, be below this, ami it 
is not necessary in eases suitable for excision to take away so much bone as to approach 
this line. Where there is necrosis or caries deeply involving the epiphysis a thin section 
only should be removed, and tin- diseased part then gouged away, leaving all the sound 



1 Vide Rev. de Chir. March 1885. 



630 Diseases of the Joints 

bone. We have excised with a perfectly successful result, removing a sequestrum from 
the lower end of the femur so large that it reached above the epiphysial line. It is by no 
means necessary for success in excision of the knee to take away healthy bone up to the 
end of a carious or necrotic cavity. We usually make the femoral section with a Butcher's 
saw from behind forwards, but there is no special importance in the method of doing it. 
All the pulpy tissue should be cut away, and all abscess cavities carefully scraped out. 
The two halves of the patella are then stitched together with stout catgut or wire. A 
simple plan is to pass the catgut round the bone — i.e. through the quadriceps and the 
ligamentum patellae — but in young children a needle will readily penetrate the soft bone 
or cartilage. The patellar ligament at the end of the operation often seems lax and 
redundant : to avoid this some surgeons remove part of the patella ; this is, however, un- 
necessary, as the parts soon adjust themselves. As to wiring the femur and tibia together, 
or pegging them with steel or ivory pegs, or mortising the ends of the bones, good as the 
plans may be in adolescents and adults, in children they are unnecessary, as their limbs are 
small and light, and there is but little leverage ; further, the bones are so soft that wires 
readily cut through and give but little extra security ; hence, though we sometimes 
employ these plans, we do not consider them by any means essential. When all bleeding 
has been stopped and the wound well powdered with iodoform and boric acid in equal 
parts and dressed with wood-wool wadding, the limb is fixed on a splint. As to the 
choice of splint it is a much simpler matter in children than in older patients, since the 
limb is short and light, and displacement is much less likely to occur. We now generally 
use a simple interrupted wooden splint, and at the first or second dressing give chloro- 
form and fix up the limb in plaster of Paris strengthened with iron strips. Howse's 
excision splint, padded with wood wool and fixed on with plaster of Paris or bees- wax 
and paraffin, is a very good apparatus, but somewhat more troublesome to use. We 
usually mould the iron strips of Paul's splinting along the sides of the limb instead of the 
back and front : there is thus less interference with drainage should the wound not heal 
by primary union, and less difficulty in keeping the splint clean. Drainage of the 
excision wound, if required at all, should always be through openings at the back of the 
joint : a director or raspatory is thrust through from within at each side of the popliteal 
space, and then cut down upon from outside ; the whole of the excision wound is then 
able to be stitched up. 

As soon as the anaesthetic has passed off, opium should be freely given. 1 
As soon as the wound is healed, or in less favourable cases as soon as only 
sinuses remain open, the limb should be fixed afresh in a plaster splint or 
put upon a Thomas's splint, and in about two months the child may be 
allowed to get about with a patten and crutches ; but the case is by no 
means done with, since nearly every case of excision of the knee in children, 
unless thoroughly well looked after and a stiff apparatus kept constantly on 
for from two to four years, according to the child's age, will become crooked. 
Occasionally, after excision of the knee, a more or less movable joint has re- 
sulted, but w r e do not look upon this as an object to be aimed at, but rather as 
a failure of the operation, inasmuch as flexion and dislocation are likely to 
result where no bony union is obtained. Flexion, with dislocation backwards 
and outwards, is the common deformity, but we have seen a general curve of 
the limb develop, or distortion at the epiphysial line of the tibia. This de- 
formity is the great difficulty and drawback in excision of the knee ; the 
operation itself is not a very dangerous one : we did some twenty-five cases 
in children without a death, though some required subsequent amputation 
— this was the end of four of our first twenty-three cases. In recent years 

1 TH i for each year of the child's age is the usual dose, and this should be repeated in 
an hour or more if required 



Deformity from Disease of Knee 



631 



we have hardly ever excised a knee ; this operation has in our practice been 
almost entirely superseded by erasion. 

The amount of shortening resulting varies much : in three cases, after an 
interval of about three years, it averaged ii inch. Though the results after 
excision of the knee are necessarily imperfect, it must be remembered that 
they are to be compared with prolonged suffering, danger to life, and ampu- 
tation as the alternatives. 

In neglected cases of disease of the knee, even though the disease may 
have to a great extent subsided, the joint often remains flexed and subluxated 
to such a degree that the limb is nearly 
or quite useless. If there is well-marked 
dislocation backwards, little can be 
hoped for in the way of reduction; all 
the tendons and ligaments become so 
shortened and contracted that, except 
in a recent case, little good can be done 
by extension or attempts at straightening 
— indeed, in some cases these attempts 
only make matters worse. Where there 
is flexion, but no, or only slight, displace- 
ment, extension by weights should be 
patiently used for some weeks ; if no 
result follows, chloroform should be given 
and an attempt made to straighten the 
limb by forcible, though not violent, 
manipulations, frequent extension and 
flexion movements being employed to 
break down any adhesions in or around 
the joint. Should it be clear that mus- 
cular contracture is an important factor 
in the resistance, the tight hamstrings 
should be divided, but we would dissuade 
from any violent efforts, especially if there 
has been much suppuration in the popli- 
teal space : in such cases there is much 
risk of laceration of vessels. Should 
the attempt succeed, the limb is brought 
straight, fixed upon a back splint for a day or two, and then an immovable 
apparatus or Thomas's splint applied. Joints will often straighten when 
somewhat flexed and even when slightly subluxated, merely by prolonged 
wearing of a Thomas's splint. 

Should it be found impossible to straighten the limb by these means, the 
choice lies between excision of the joint and osteotomy. We have employed 
both with good results, but they are applicable to somewhat different con- 
ditions. Suppose the joint allows considerable movement although it can- 
not be straightened sufficiently to be of use, osteotomy is likely to Leave an 
unsteady limb ; on the other hand, an acutely flexed limb requires removal 
of a very large amount of bone in excision before the leg and thigh can be 
brought into a straight Hue. We think, then, that osteotomy is best for 




ig. 129 



-Shows the result of premature use 
of the limb after excision. The operation 
had been done at another hospital, and the 
patient was subsequently admitted under 
the care of our colleague Mr. T. Jones 
There was bony anchylosis in the position 
seen in the fisrure. 



6^2 



Diseases of the Joints 



\ 



a 



cases of stiff joint with great flexion, excision for those where there is 
more mobility, less flexion, and more displacement. The late M. Beck and 
B. Pollard advocate division of the crucial ligaments with subsequent re- 
duction in cases of subluxation, and have recorded a few cases ; we think 
the application of the method likely to be limited, since division of these 
ligaments certainly does not allow of reduction in all cases. 

Osteotomy in such cases is not a difficult operation ; a longitudinal in- 
cision is made about three or four inches in length on the front of the thigh 
from the patella upwards, the femur is exposed, and a sufficient wedge of 
bone removed from its anterior surface to allow 
the limb to be brought straight. We prefer this 
plan to simple section, which may cause dangerous 
pressure on the popliteal vessels, and be followed 
by gangrene. In one of our cases after excision 
we could not nearly straighten the limb at the 
time, but by keeping up extension after the excision 
the limb was gradually brought almost straight. 
The following case illustrates the value of osteo- 
tomv in certain circumstances : 



Case.— Necrosis of Tibia. — Angular Flexion of Knee. 
Osteotomy. — Ralph H., age 13 years ; admitted January 12, 
1885. History good ; well till two years ago ; complained 
of pain in knee, which soon swelled ; no cause known ; 
twelve months later had some dead bone taken from the 
leg ; discharge has continued till now. On admission, 
well-nourished boy ; was sent in for amputation ; the left 
tibia is enlarged and longer than the right ; on the inner 
side are scars of former operations, and a large sinus over 
the upper end of the bone ; the leg is flexed nearly to a 
right angle ; hamstrings tense ; toes pointed ; foot cannot 
be straightened. 24th, has had 6 lbs. extension on since 
admission, but the knee is no straighter. February 12, has 
had on a Thomas's knee splint since last note, and has been 
getting up ; no improvement. 13th, under chloroform an 
attempt was made to straighten the limb forcibly ; a few 
adhesions gave way, but no sensible improvement followed ; 
back splint. 20th, an incision 3 inches long was made in 
the axis of the femur above the knee, the periosteum was 
peeled back, and a large wedge of bone removed with an 
then be nearly straightened ; operation antiseptic. 24th, 




Fig. 130. — Splint for disease 
of the Ankle and Tarsus. 
It is made of iron, covered 
with india-rubber tubing, 
as suggested bv Mr. Paul. 
The splint is fixed to the 
limb with plaster of Paris 
bandages. 



osteotome ; the limb could 
tube removed. March 11, limb put up in back splint with movable foot-piece; wound 
healed and limb straight. 20th, fair union of shaft ; leg straight ; foot in good position ; 
gets up with the Thomas's splint. Sent home on 24th. January 30, 1886, leg straight, 
walks without splint, sound and well ; toes still somewhat pointed. 



In another recent case the joint was much flexed, but mobile through a 
certain range ; on excising the joint it was found impossible to straighten 
the limb without greatly shortening it, so an osteotomy was done at the 
junction of the lower and middle thirds of the femur, and the limb was then 
brought into good position. 

Treatment of Pulpy Disease of the Ankle Joint. — The same general 
rules apply to the treatment of tubercular disease of the ankle as to that of 



Pulpy Disease of Ankle 633 

the knee in the earlier stages of the disease, and many good results will be 
obtained by simple pressure and fixation. To carry out this plan the best 
means are to use either the apparatus shown in fig. 130, or a short metal 
back splint with a foot-piece, the child being allowed to get about with a 
Thomas's knee splint. Should suppuration occur, and the joint not recover 
by the means described, the prospect is a somewhat poor one : however, 
erasion and resection of the ankle for tubercular disease are now fairly 
satisfactory operations, though the disease sometimes spreads, and amputa- 
tion is required. Amputation is, however, in these days almost a discarded 
operation, except at the hip joint, at least so far as the surgery of childhood 
is concerned. We have not amputated a limb at the Children's Hospital 
for joint disease during the last three years, except in one case where the mis- 
chief in the knee was the result of extension in a case of acute necrosis. A 
patient trial of fixation, pressure, and, if necessary, repeated removals of the 
disease should be given, even after suppuration occurs, provided the child's 
health is maintained, but the prospects of such cases in disease of the ankle 
are not nearly so good as in the knee. The following is an instance of a 
satisfactory result after erasion of the ankle : 

Case. — Peter H. , age 8 years 8 months ; admitted January 30, 1882. Ten weeks ago the 
right ankle became swollen ; no cause known ; had been treated with cold water, strapping, 
&c. ; never had much pain in it. On admission, fairly nourished but muddy-complexioned 
boy ; there was much swelling round the right ankle joint on all sides, with increased heat 
and redness on the outer side, but little or no tenderness to pressure, though movement 
of the joint was painful ; the circumference was an inch and three-quarters greater than the 
opposite side ; the position was semi-extended and rotated slightly inwards. On February 
9 the joint was opened by a transverse incision (Mr. Holmes's plan) across the front of 
the joint divkling all the extensor tendons, &c. ; much pulpy synovitis existed with ' sub- 
chondral caries ; ' all the pulpy tissue, as well as the loosened cartilages, was removed as 
far as possible, and a drainage tube passed across the joint, a groove being cut in the 
upper surface of the astragalus to prevent the tube from being nipped ; the tendons were 
then stitched together with catgut and the wound closed ; no attempt was made to unite 
nerves, and the anterior tibial artery was twisted ; sponge pressure was applied around the 
joint, and the operation was antiseptic ; finally the limb was fixed on a back splint with a 
foot-piece ; a little oozing followed at the first dressing ; on the following day the appear- 
ance of the foot was natural below the line of incision ; a little superficial ulceration 
occurred at the outer aspect of the front of the .foot, and union of the edges was slow, but 
by March 13 the incision had healed except at the drainage-tube openings ; no pus had 
been discharged up to 1 his date. On April 20 some sensation was perceived on the dorsum 
of the foot. There was no discharge, and on May 28 he was sent out with plaster of 
Paris over an Esmarch's splint and a sponge dressing still applied ; after this progress was 
very slow, some thickening remaining about the ankle, and occasionally a small part of 
the cicatrix; would ulcerate and break down. February 1885, foot sound and well, but 
toes are somewhat pointed, and he ' throws ' the foot in walking. He gets about well with 
a boot and without any support. A good deal of new bone formation about line of incision 
but some mobility. 

We have also had some excellent results after excision of the ankle. 

CASE. — Disease of Right Ankle. Necrosis of Astragalus. — Richard T. . age 4 years 
5 months ; admitted September i8, 1882. Family history good. History : Well till six 
months ago, when the ankle began to .swell and has gradualh gotworse; no pain; DO 
injury; can walk. On admission, fairly health) child; somewhat ricket} : right ankle 
swollen ; bulging on each side of extensor tendons and round each malleolus, especially 
on inner side and in front of tendo Achillis. September 30, ankle joint aspirated ; a little 



634 Diseases of the Joints 

serum drawn off. and some tr. iodi injected. October 20, no improvement ; an incision 
behind the inner malleolus gave exit to two teaspoonfuls of gelatinous and almost melon- 
seed-like material. October 28, wound healed ; joint refilled. November 16, tempera- 
ture rose ; io4 > 2° on 18th. November 23, joint opened ; a large, loose sequestrum of the 
astragalus was found and removed ; the whole astragalus was then taken away, and the 
lower end of the tibia and fibula resected, as well as the upper surface of the os calcis and 
the inferior tibio-fibular joint. The joint was opened by a transverse incision across the 
front; the tibial and extensor tendons were stitched together afterwards. Operation anti- 
septic ; sponge pressure, and subsequently salicylic silk. January 13, antiseptics left off ; 
had been doing fairly, but slowly ; still some swelling. February 11, sent out in plaster of 
Paris over an iron splint round foot ; wound not healed. He finally got a good sound 
foot. 

If excision is performed the astragalus should always be removed entirely 
and all tubercular material taken away ; there is then a fair prospect of a good 
foot, and only when this fails should amputation be done. The prospects 
after excision are much better now than they were before recent improvements 
in the management of such cases. We have had -some very satisfactory 
stumps after PirogofPs operation, and watched them for years ; and, although 
it occasionally fails, where it is successful it gives a much better stump than 
Syme's amputation. If removal of the foot is too long postponed, disease is 
apt to spread up into the tibia and along the sheaths of the tendons, and 
then amputation higher up the limb will be called for, but the question of 
amputation, as already pointed out, very rarely arises. See also treatment 
of Tarsal disease. 

Treatment of Tarsal Disease. — It has already been pointed out that, 
except in the case of the os calcis, disease of the tarsus is usually synovial 
in origin, hence it should be treated on the general principles of such lesions 
— absolute fixation of the foot, with entire rest from any strain — and the usual 
hygienic means should be employed in addition. The apparatus already 
referred to for disease of the ankle is the best means with which we are 
acquainted of carrying out this plan, and to it a patient trial should be given. 
Should, however, this treatment fail, two courses are open : one that of com- 
plete removal of the disease by amputation, the other that of removal of the 
diseased parts alone. It is impossible here to fully discuss the question, but 
the conclusions to which our experience has led us are these. If there are 
definite sequestra of one or more tarsal bones, these should be removed, 
and an attempt made to save the foot ; the fact of there being necrosis often 
means that there is a line of demarcation formed and recovery may follow. 
It cannot be stated absolutely, because, as already pointed out in the case 
of the leg, even where sequestra exist tuberculous infiltration of surrounding- 
bone may be present. If there is general synovial disease with caries, it is 
best to freely expose the affected parts by turning up a dorsal flap of the soft 
structures and removing the diseased tissues, but so long as any affected 
synovial membrane or carious bone remains recurrence is to be expected. 
In such cases the best plan is total resection of the tarsus— i.e. removal of all 
the tarsal bones, with or without the exception of the back part of the os calcis, 
which, if sound, may be left to form a support for the heel. 

The simple transverse dorsal incision turning up a dorsal flap is, we think, the best 
method ; it fully exposes the parts, the divided tendons can be stitched together afterwards, 
and the use of the foot is wonderfully little impaired. After the operation the foot may 
be at first kept merely upon a back splint with a foot-piece, but as the cavity begins to fill 



. 



Tarsectomy 



63 



up and the parts consolidate, the iron splint (Paul's splint) with plaster of Paris forms the 
best appliance. 

By this method excellent results, far superior to those obtained by a 
PirogofPs or Syme's amputation, will be obtained (fig. 131). 

Case. — Annie E. , age 17, sprained her foot in the winter of 1883-84, and came under 
our care in the Royal Infirmary in November 1884. She was then a fairly healthy-looking 
girl, with disease of the anterior calcaneo-astragaloid and astragalo-scaphoid joints, as 
well as swelling of nearly the whole foot ; there was a sore below the inner malleolus. After 
treatment by rest and fixation part of 
the astragalus and scaphoid were re- 
moved in January 1885. In May the 
disease was still progressing, and the 
whole of the tarsus, with the exception 
of the posterior part of the os calcis, was 
taken away, the bases of the metatarsal 
bones and the malleoli being also re- 
moved ; some of the tendons were 
stitched together, otherwise no attempt 
at adjustment of the deeper structures 
was made. In the spring of 1886 the 
foot was as seen in fig. 131 ; she could 
' spring ' upon it to a certain extent ; 
there was fair mobility and power ; and 
she did her housework with no other 
support than a Martin's bandage. — Vide 
Med. Chron. September 1886. In 1891 
the foot still remained sound. We have 
had a good many similar cases. 




-Shows a foot after resection of the whole 
Tarsus on the left side except the back of the os 
calcis. Annie E. Both feet are flat. 



Should the disease recur, am- Fig. 
putation may possibly be required, 
but this is far less likely to be ne- 
cessary than after mere gouging or scraping operations. Partial resection 
of the tarsus, except for necrosis, is rarely successful — i.e. where there is 
mischief spreading about among the tarsal joints it is of little use to remove 
merely an individual bone or two bones. Unless a clean sweep is made 
of the disease it will probably recur. The exception to this rule is the os 
calcis, but as in this bone the disease is usually central, it stands by itself : 
removal of the entire os calcis without any other bone is a highly successful 
and very valuable operation, and is often called for. 

CASE. — Disease of Calcaneo-astragaloid Joint. Caries of Os Calcis. Excision. — 
Norman G., age 2 years 4 months ; admitted June u, 1883. Family history: phthisical. 
History : measles ten months ago ; swelling of foot followed ; has been under treatment 
for it. On admission, sinus in sole of right foot over calcaneo-cuboid joint, another 
below outer malleolus ; much thickening about os calcis, movement of ankle free. 
June 14, explored ; sinus led into os calcis, and probably to calcaneo-astragaloid joint; 
drainage. July 7, put up in plaster of Paris with ankle splint and discharged : splint had 
to be removed in a few days on account of swelling; back splint put on ; had varicella 
July 11. Readmitted July 24, foot worse; discharge increased. August 1, flap turned 
forwards from heel, and os calcis excised ; found carious, with a large cavity ; operation 
sub-peri osteal ; did well; discharged August 25. February 1884, the foot healed and 
become sound and useful; a small fresh collection of pus has, however, just reformed; 
the os calcis has been largely reproduced, and the foot is fairly well shaped. Ma\ 188;. 
sound and well ; walks excellently. 



636 



Diseases of the Joints 



The treatment of tarsal disease, then, is rest and pressure first ; failing 
this — and it should have full trial— removal of sequestra if there are any ; 
if not, resection of the whole tarsus, or at least of such part of it as shall 
include all the joints communicating with the seat of disease. If disease still 
goes on, Pirogoff's or Syme's, or, of course rarely, Chopart's operation, as the 
disease may demand ; for disease of the os calcis removal of it alone is the 
better plan, and when done subperiosteal^ there is usually a most perfect 
reformation of bone (fig. 132). 

After total resection of the tarsus we much prefer to keep the foot in its 
natural position and allow the parts to adjust themselves, rather than arti- 
ficially produce a sort of equinus foot as proposed by Wladimiroff. 

Conner, in a paper in the American Journ. of Med. 
Sci. October 1883, relates 108 cases of resection of the 
tarsus in which two or more bones were removed, inclu- 
ding two cases of his own in which the entire tarsus was 
taken away through an incision along the outer side of 
the foot. He concludes that the mortality is not much, 
if at all, greater than that of amputation at the ankle 
joint ; that it can be followed by amputation if neces- 
sary, and in 68 of the 108 cases the result was good. A 
paper by one of the present writers in the Medical 
Chronicle, 1886, may also be referred to. 



Disease of the phalanges and metatarsal 
bones of the toes differs in no way from the 
corresponding disease of the fingers, and re- 
quires the same management except that 
amputation may be resorted to in the foot 
earlier than in the hand, since the loss of a toe 
is of less consequence than that of a finger. 
Disease of the first metatarsal bone and of the metatarso-phalangeal 
joint of the great toe is common, and of importance, since it is liable to be 
followed by considerable lameness. . Failing rest and general measures, the 
question of amputation or resection remains ; either is followed by a certain 
amount of crippling, but resection of the first metatarsal bone is so frequently 
unsuccessful that the most speedily satisfactory result is probably that of 
amputation. We usually resect the bone as a first resort, and only amputate 
failing this ; but we must confess that even when resection succeeds the toe 
is so shrunken and short as to be of little use. 

Sacro-iliac Disease is not very rare in children ; it is usually, we think, 
the result of extension of chronic tubercular disease from the adjacent bone, 
most often the ilium — at any rate, necrosis is common, and we have removed 
sequestra which included the articular surface of the ilium. The disease 
usually runs a chronic course, and gives rise to comparatively little pain ; 
often attention is first called to it by the presence of an abscess over the back 
of the joint ; sometimes, however, the matter forms at the intrapelvic surface 
and may point in the groin or track down behind the rectum : under such 
circumstances there may be pain down the leg from pressure upon the sacral 
nerves. Pain is sometimes felt in walking from the weight of the body bearing 
upon the diseased joint, and pressure directly upon the joint or upon the 




ig. 132. — Shows the result of excision 
of the Os Calcis. There is nearly 
complete restoration of the bone. 



Disease of Temporo-maxillary Joint 637 

iliac crests, or, again, traction upon the iliac crests, tending to draw them 
backwards, gives rise to pain. It is occasionally possible to make out 
mobility of the ilium upon the sacrum, and we have seen displacement of 
the bones as a result of disease. Caries of the spine may cause sacro-iliac 
disease from the burrowing of pus'into the joint, and in most of the cases we 
have seen there has been disease of bone or joints elsewhere. 

Sacro-iliac disease is best treated by rest in bed on a firm mattress, no 
sitting up being allowed. Should an abscess form and increase in size in 
spite of treatment, it should be opened and any diseased bone removed ; as 
soon as the acute symptoms, if any are present, have passed off, the child 
should have a double Thomas's hip splint applied, the splint being fixed on 
with plaster of Paris round the limbs and above the joint : he may then be 
moved out of doors on a couch with safety. If the position of the abscess 
prevents the application of the splint in the ordinary way, the apparatus may 
be so arranged that on the affected side the splint is applied to the outer 
side instead of to the back of the limb {vide figs, in chapter on Spinal 
Disease). If the child recovers, there will probably be some arrest of growth 
of the pelvis on that side, and a lateral curvature of the spine. 

We have not seen a case of acute non-tubercular sacro-iliac disease, and 
the strength of the articulation is such that any acute traumatic mischief is 
unlikely to be met with. 

Disease of the Temporo-maxillary Joint occasionally occurs in children 
as the result of scarlet fever, injury, or necrosis of the jaw or of the temporal 
or malar bones, or arises by extension from the ear, and gives rise to stiffness 
and inability to open the mouth, and later to distortion of the face from 
arrest of growth. Pain in movements of the jaw and swelling over the 
joint are the usual symptoms ; when suppuration occurs it usually points 
over the articulation. We have seen the joint suppurate in a case of 
pyaemia which was associated with acute suppurative arthritis in an infant. 

The treatment consists in opening the abscess, should one form, and the 
child should be fed on soft food ; unnecessary disturbance of the joint is to 
be avoided. Should the jaw become stiff, attempts should be made to over- 
come the stiffness by means of a Maunder's screw,. used several times daily 
after forcible opening of the mouth under an anaesthetic, just as in peri- 
articular adhesions from suppuration in the neighbourhood of the joint. 

Case. — Spurious Ankylosis of Jaw, with Atrophy of the Bone. — Thomas C. , age 
8 years 4 months; admitted June 21, 1882. Had 'low fever and inflammation of the 
lungs ' at two years old, and since then his jaw has been stiff, so that he lives on liquids 
and sop ; was thought to have hydrocephalus ; soon after he became ill he had otorrhcea, 
which continued until the time of admission with intervals. On admission was only able 
to open his mouth about a quarter of an inch ; nearly all his teeth were caiuais he spoke 
fairly well and seemed to be in good health ; the jaw was much atrophied, so that the 
upper teeth far overhung the lower ; the jaw was forcibly prised open under chloroform, 
and subsequently Maunder's screw was used, with the result of increasing his s;ape to 
more than an inch, and enabling him to masticate fairly well ; the use of the screw has 
been continued up to present date, February 1883. 

Failing this plan one of the forms of operation for the establishment of a 
false joint should be performed ; probably the most satisfactory in permanent 
results is resection of the head of the bone by an incision parallel to and 



638 Diseases of the Joints 

below the zygoma, taking care to avoid injury to the facial nerve, but we 
have not met with a case requiring the operation. 1 

Disease of the Acromio-clavicular and Sterno-clavicular Joints is 

occasionally met with ; it should be treated by fixation of the arm to the side. 
If suppuration occurs the joints should be freely opened and the tuberculous 
material removed. We have found sequestra in the acromio-clavicular 
joint {vide General Surgical Tuberculosis). A certain amount of 
disability in use of the limb may result. 

' Hysterical Joints ' {vide chapter on HYSTERIA). Though the utmost 
caution must be used before deciding that any joint trouble in children is not 
due to organic disease provided persistent complaint of the joint is made, it 
is an unquestionable fact that cases of so-called ' Hysterical joints ' are occa- 
sionally met with. We have seen children with such a condition affecting 
the spine and more rarely the hip. The great clue to the nature of the case 
is the incompatibility of the objective signs with the complaints made by the 
child. If with a history of long-continued complaints there is no local evidence 
of disease, and if the site of the alleged pain is inconsistent with the known 
nerve distribution, and if also the pain is exaggerated, we should carefully 
consider the possibility of a 'neurosis,' and this the more if the personal and 
family history supports such a view. We have recently (1895) seen a girl 
of about 12 years of age, who a fortnight after being sent to work complained 
of pain in the hip and subsequently in the knee. She was supposed to be 
suffering from hip disease. On examination she was a stout, healthy, but 
excitable-looking child. She walked a little lame, and complained of pain 
in the region of the anterior superior spine of the ilium and in the knee. 
There was neither swelling nor rigidity of the joint, but alleged great 
tenderness on pressure. Further examination showed that pressure on 
various other points gave rise to extreme expression of pain, but by leading 
questions complaint could be elicited of pain in other parts of the body where 
there was no reason at all to suspect the presence of disease. The complaints 
were incompatible with what we know of organic disease, and the case was 
clearly shown to be hysterical. 

1 Or Mr. Spanton's plan of dividing subcutaneously the resisting structures in and 
around the joint [vide Mr. C. Heath's lectures, Brit. Med. Jour. July 9, 1887). 



639 



CHAPTER XXVIII 



HIP DISEASE 



Hip Disease l in the ordinary sense of the term— i.e. tuberculous disease 
of the hip joint -is almost entirely an affection of childhood ; thus only 73 
patients, the subjects of this disease, were over twenty years of age out of a 
total of 619 cases collected by ourselves, and probably in most of these the 
disease had begun at an earlier age. It is somewhat more commonly met 
with in boys than girls, and is much more frequent among the poorer than in 
the well-to-do classes. Mention has already been made in general terms of 
the pathology and causation of the disease : that the hip may be taken as the 
joint in which primary tuberculosis of the bones forming the articulation is 





Fig. 133.- Diagram showing at a, a (in 
vertical shading) the parts most commonly 
affected in Hip Disease, n is the trochan- 
teric epiphysis. The lower a points to 
the ' calcar.' (Altered from Barwell.) 



Fig. 134.— There is a large sequestrum in ihe 

neck. The heal, which is still cartilage- 
covered, but i> almost detached, is pr pped 
up by a quill. Vascular perforations are 
seen in the marginal cartilage. Removed 
post mortem. 



most frequent. Indeed, our own belief, based mainly upon examination ot 
some 150 cases of excision of our own, is that in true chronic morbus coxie, 
such as we ordinarily see, and also in the acute and rapidly destructive cases, 
the disease begins almost invariably in the bone. In older patients a primary 
synovitis is more frequent, but in children an acute, subacute, or chronic 
inflammation of the upper epiphysis of the femur or its neighbourhood is by 
far the most common condition. In some cases the disease begins in the 
neck of the femur, and when this is so it is generally the under surface that 
is attacked, and this is the part on which the greatest strain comes in injuries 

1 For a more detailed account o( Hip l )i>o;\s • in Childhood than space allows 
the reader is referred to 'the monograph l>\ one of the present writers : . 
Childhood, by G. A. Wright (Longmans & Co., 1887). Also to a work by Pr. R. \Y. 
Lovett of Boston, 1802. 



640 



Hip Disease 



applied direct to the trochanter, and also the part least abundantly supplied 
with vessels (figs. 133 and 134). 

In some cases the disease is primarily acetabular, but much more fre- 
quently the initial lesion is femoral, though rapid destruction of the acetabulum 
may occur secondarily. In one hundred cases of our own the acetabulum 
was necrosed or perforated in twenty-seven, but in many of these the disease 
was probably primarily femoral. The part of the epiphysis usually first in- 
volved is the immediate neighbourhood of the epiphysial line. The occur- 
rence of synovitis of the hip joint is not, of course, denied by us, but we believe 
that two entirely different classes of cases come under observation : the one is 
a simple synovitis, usually traumatic, a lesion that occurs in the healthy and 
unhealthy alike, and is as amenable to treatment in the hip as elsewhere. 
The other class is one composed of tuberculous patients ; from some injury, 
or even slight overstrain only of the part, the cancellous tissue of the bone 
has its normal circulation slightly interfered with ; inflammation follows, and 
inflammation in a tuberculous subject is only too prone to follow the usual 
course of a tuberculous lesion, and the special anatomical features of the hip 
joint make it especially liable to serious and progressive disease. Necrosis 
of the pelvis or femur is common in the course of this disease ; thus in our 
first hundred cases of excision there were seventeen instances in which 
sequestra were found, either in or detached from the femur, and the aceta- 
bulum contained sequestra in twenty-two cases. 



The naked-eye characters 
are the following : The carti 




both sides of the epiphysial 
line. On the under surface of 
the neck is the rough depres- 
sioncaused by pressure against 
the rim of the acetabulum. 
There was pathological dis- 
location. A section has been 
made through the upper end 
of the femur. 



of a typical specimen from hip disease in an advanced stage 
lage is all gone or hanging in tags or worm-eaten plates, or 
it may be merely loosened and thinned with a layer of 
granulations underlying it (fig. 135) ; the synovial mem- 
brane is red and vascular, somewhat thickened, but rarely 
to anything like the degree already described in the case 
of the knee joint. The bone, as seen in section, varies 
somewhat, but certain characters are very constant. 
Sometimes the whole upper epiphysis is detached and 
forms a hard, loose, marble-like sequestrum ; in a larger 
number the upper epiphysis is destroyed to a greater or 
less extent : sometimes only a small part of it is actually 
gone, but in all it is of a dull yellowish-white colour. In 
some late cases the colour is opaque, and the bone is 
putty-like, with or without obvious rarefaction ; in earlier 
cases there is a mottled appearance, patches of dark red 
hyperaemic bone alternating with dull yellow areas, and 
here and there a soft patch of granulation tissue. Se- 
questrum may be present, and the epiphysial cartilage may 
be little altered, perforated, or entirely destroyed. 



Occasionally the disease spreads far down the shaft ; more commonly 
the bone below the level of the great trochanter is congested, with more or 
less rarefaction, but no extensive disease. Corresponding lesions are found 
in the acetabulum, which is often rough and eroded, and its walls absorbed, 
so that the cavity is wider and shallower than in health. Occasionally there 
is very extensive caries or necrosis of the pelvis, and, indeed, nearly the 
whole innominate bone may be diseased. It must be remembered that even 
when the pelvis is perforated there is a thick wall of dense fibrous material 



Etiology and Pathology 



641 



intervening between the pelvic organs and the joint cavity, so that, although 
the bone is bare on both aspects, and much of it requires removal, there is no 
danger of injury to the viscera. The joint itself usually contains pus and 
false membrane, with broken-down caseous granulations and detritus. The 
conditions commonly found in the acetabulum have been already mentioned ; 
it should, however, be stated that in the later stages of the disease what is 
called 'travelling acetabulum' maybe produced where repair to some extent 
is going on ; the rim of the acetabulum is destroyed by what looks like a sort 
of ploughing-up process, and when repair begins new bone is formed higher 
up on the dorsum of the ilium to form a socket for the end of the femur. In 
some instances the innominate may be separated into its component bones, 
as in two specimens in our collection. (See fig. 136.) 

In other cases suppuration may occur within the pelvis, either as a result 
of perforation of the acetabulum or of extension of inflammation through the 
thickness of the bone, or of pus, as it not 
unfrequently does, tracking over the brim 
of the pelvis and then gravitating down- 
ward. We have seen several cases where 
pus has burrowed up the sheath of the psoas 
and so got within the pelvic cavity. 

The remains of the head of the femur 
may lie in the little-altered acetabulum, or 
be drawn upward upon the dorsum, or even 
project through the acetabulum into the 
pelvis ; it has been found fixed to the ace- 
tabulum, though quite detached from the 
femur, or, rarely, firmly impacted, as we 
have seen it. The amount of acetabular 
disease depends, apart from the possibility 
of the origin of the affection there, upon the 
fact that when once the joint cavity is in- 
volved, a large surface — i.e. the whole aceta- 
bulum — is at once exposed to irritation, and 

SO the process in it is more rapid ; it also Fig. 136.— Shows extensive Acetabular 

depends upon how much the head of the &fi^^£y&**5 

femur has been allowed tO preSS Upon the 1S largely necrosed , white scale-hke 
, • patches of new bone are seen on the 

pelVlS. surface. The disease was acute. 

It is very rare to find any attempt at a 
new formation of bone while the disease is progressing", while, after removal 
of the upper end of the femur, new bone may be rapidly formed ; in this, of 
course, the hip resembles other joints. This rapid formation of new bone 
after excision is a strong indication for that operation, in that it shows that 
nature is unable to begin repair until the disease is removed. 

The etiology and pathology of morbus coxae, then, may be summed up as 
follows : 

1. Hip disease is dependent upon that deficient power of recovery and 
tendency to caseous degeneration which may be called the strumous 01 scrofu- 
lous, or, better, the tuberculous diathesis, and this constitutes the predisposing 
cause. The disease is, in fact, a local tuberculosis. 

r r 




642 Hip Disease 

2. Any slight or severe injury, over-use, &c, or the onset of a specific 
fever, may, in such a constitution, prove an exciting cause. 

3. Injury in a healthy child may produce synovitis, or even acute inflam- 
mation of bone about the hip, as elsewhere, but this does not, except very 
rarely, lead to chronic hip disease. 

4. In the vast majority of the cases of morbus coxae the disease begins 
as an osteomyelitis of the upper epiphysis of the femur, or of the immediate 
neighbourhood of the epiphysial line. 

5. This particular osteomyelitis tends to destruction, and usually runs a 
chronic course with caseation of the inflammatory material, and resolution 
can rarely, if ever, be expected when the disease is well established. 

6. The occurrence of the disease in childhood is explained by the physio- 
logical and anatomical peculiarities existing before puberty. 

Besides the common chronic hip disease, there is a form of acute hip 
disease which may run its course in a few weeks, or even days, and produce 
as much or more destruction of parts than months or years have in the chronic 
cases. Instances of this condition are not very rare ; every hospital surgeon 
sees them occasionally. Some of these cases are probably pysemic, others 
belong to the class of ' acute suppurative arthritis of infants' {vide p. 622) ; 
others, again, are acute traumatic inflammation, synovial or osteomyelitic : 
possibly in some partial separation of the upper epiphysis may occur, with 
rapid necrosis ; others, again, are probably cases of acute periostitis of a 
nature similar to that occurring in the shaft of the femur, tibia, &c. These 
last may result in widespread suppuration and necrosis of the pelvis and 
femur. An acutely destructive condition may come on in the course of 
chronic disease. 

Lastly, acute tuberculosis sometimes leads to rapid suppuration. 

Symptoms. — In describing the symptoms of hip disease it will be con- 
venient to take them one by one, and discuss the views and explanations of 
each symptom before passing on to the next, and finally to group them 
together in a type case. 

Pain. — Pain is a prominent feature of most cases of hip disease from the 
beginning ; at least until complete disorganisation of the joint and displace- 
ment or destruction of the head or recovery. 

The seat and degree of pain are, however, alike very variable. Thus 
pain may be referred to the hip itself, the buttock, the back or front of the 
thigh, the knee in front or behind, or any part of the leg or foot. It may be 
localised or diffused, so that the patient strokes the whole thigh down in 
some cases when asked where his pain is, and but rarely points to any one 
spot. There is no consistent relation to be made out between the seat 
of pain and the position or extent of disease. Probably the front and 
inner side of the knee is the most frequent seat of pain. Tenderness, 
however, is often much more localised to the position of the joint, but 
even that is very variable. Pain is, undoubtedly, often remittent ; some- 
times an interval of some weeks intervenes, even without treatment, 
between the attacks. We have seen cases where the child had been walking 
about with a shortened, distorted limb, who never had any pain from 
beginning to end ; and others, with large abscesses, who have also been 
throughout free from pain ; while the agonising pain of those who have to 



Pain in Hip Disease 643 

endure 'night startings ' is only too familiar to all who have been residents 
in hospitals. 

In considering the question of pain, it is well to bear in mind the number 
of different sources of nerve supply to the joint. 

It is not practicable, nor very important, to distinguish by a knowledge 
of the nerve distribution the exact patch of synovial membrane or ligament 
that is locally inflamed : its only value, if it were possible, would be from a 
prognostic point of view ; but here history, duration, and other symptoms 
are more trustworthy. There is, however, no doubt that ' night pains ' give 
us evidence of extension of the disease to the articular surface. 

It is, then, clear that pain in cases of hip disease is variable in its seat, 
or rather that it may occur in a great many different places ; of these, 
special attention has always been paid to pain in the knee, and several 
explanations are given of this pain. In the majority of cases it is probably 
•due to ' transferred sensation ' from one of three sources, the anterior crural, 
the sciatic, or the obturator nerves, branches of which are distributed to the 
front and back of the joint. In our experience, the pain in the knee is generally 
rather vaguely referred to the front of the knee, the child passing its out- 
stretched hand over the whole of the front of the joint. The pain, in fact, is 
referred rather to the distribution of the anterior crural than of the obturator. 

Pain in the hip is not usually a marked sign in the sense of there being 
any constant pain ; tenderness on pressure over the front or back of the 
•capsule, and pain in pressing the trochanter inward or the head of the bone 
upward, is, of course, present in all acute cases, and a large proportion of the 
chronic ones. 

Night startings or pains are a prominent and important feature in acute 
and subacute cases ; they may be altogether absent in chronic disease — 
except where acute mischief has supervened upon chronic — and they may 
be absent throughout the whole course of a case. When they do occur, 
they indicate that inflammation has extended to the joint surfaces ; and 
further, that our means, whatever they may have been, of treating the lesion, 
have been inefficient so long as these startings continue. Their cause is too 
well recognised to need discussing. The rigid muscles, acting under the 
influence of 'joint sense' (Barwell), contract spasmodically to fix and 
immobilise the joint surfaces ; as sleep comes on, with its accompanying 
muscular relaxation, some friction or pressure of the tender surfaces together 
takes place, causes acute pain, a sudden awakening with a cry, and a violent 
spasm of the muscles to again fix the joint. This may be repeated many 
times in a night, and is a strong indication for treatment. These night 
pains are very uncommon after excision ; where they do occur they mean 
that disease is extending in the pelvis, and probably the femur is not kept 
sufficiently far away from the acetabulum to prevent pressure upon it : in 
such cases, then, it is well to increase the extending force, though in some 
cases too great extension may increase pain. Tenderness or pain on 
pressure lias been already alluded to. When superficial tenderness really 
exists, the fears of the child, if he has already been ungently handled, being 
taken into account, it means that suppuration has occurred in the soft parts 
and is becoming superficial, or, in very acute cases, it seems that really all 
the parts in the neighbourhood of the joint are hypereesthetic : it is certainly 

r r a 



644 Hip Disease 

the case that in no joint does inflammation extend so widely among the soft 
tissues as in hip disease. 

When, however, no pain is produced, except on deep pressure applied 
over the head of the bone, it is probable that the disease is limited to the 
bone, and has not yet set up mischief of any serious nature within the joint, 
or, at least, that any such change is a very chronic one. It is well to bear 
in mind that pressure on an inflamed ligament is very painful indeed— a 
fact easily verified in chronic synovitis of the knee — and it is possible that 
the pain in these cases may be due to extension of the disease to the capsule 
rather than to the inflammation in the bone itself. 

Certain movements of the joint are more painful in case of inflammation 
than others, and it is true that a patient may have quite or almost painless 
power of flexion of the joint, and yet be quite unable to bear rotation or 
abduction. 

Night startings may exist and be due to hip disease without any 
recollection of pain on awakening ; but Howard Marsh cautions us against 
mistaking the cries of nightmare for those of night starting. 

It is well to remember that inflamed inguinal or iliac glands may cause 
pain and tenderness, which must be distinguished from that of the joint itself. 
Lameness. — Limping or lameness is the symptom usually first noticed by 
the parents in the case of children with chronic hip disease. Even this, 
however, may be preceded by a feeling of tiredness or ill-defined aching 
about the limb after exercise, the aching passing off after rest, but recurring 
again after less and less exertion. The limping may be quite painless at 
first, and differs in appearance from the well-marked ' drop ' seen in later 
stages, when there is shortening of the limb. At this time the child generally 
shows a tendency to rest the affected leg, and throw the weight upon the 
sound limb at every opportunity. Later, well-marked lameness comes on, 
and is accompanied by pain. It is at this time that the mistakes in diagnosis 
are so often made ; the obvious symptoms are lameness, and often pain in 
the knee or thigh ; there is no other marked sign, and the condition is sup- 
posed to be disease of the knee or ' weakness ' with ' growing pains,' and so 
on. This stage requires careful and exact investigation to discover it, and 
at the same time is the period at which treatment is most effectual. Later 
in the disease lameness is due either to actual shortening, or to tilting of the 
pelvis to take the strain off the tender limb, or to flexion. 

Heat. — Increased temperature in the joint is, of course, only perceptible 
where the inflammation is acute, and from the thickness of the parts cover- 
ing the joint is not readily ascertained ; it is not, therefore, a symptom of 
much value, except in the third stage, where superficial swelling combined 
with heat indicates the presence of suppuration outside the joint. In some 
cases of acute synovitis, pure and simple, a local rise of temperature may 
be made out, and is a valuable indication of acute inflammation of the soft 
tissues. 

Swelling. — Swelling is one of the most important symptoms. In the 
first place, local swelling over the front and back of the joint — i.e. just 
external to the femoral vessels or pushing them forward, and just behind 
the trochanter, obliterating the normal hollow — indicates effusion into the 
synovial sac, and, with a recent history of injury, indicates an acute synovitis.. 



Muscular Spasm — Rigidity 645 

AVith a longer history such swelling is due to the secondary inflammation of 
the joint by extension from osteomyelitis. 

Swelling of the great trochanter indicates suppuration, or rather caseation 
■within the joint, and when well marked we believe may be relied upon as 
pathognomonic of it ; it is true that this thickening may disappear under treat- 
ment, but none the less has there been puriform material there which has been 
absorbed as far as its fluid portion goes, and if once that thickening has 
occurred we do not think any case is free from danger of relapse. This 
thickening results from extension of the disease from the interior of the bone 
to the surface, and, as soon as the cavity of the joint is involved, suppuration 
almost invariably occurs, though of course not necessarily outside the joint. 

Periarticular or 'adjacent' abscess certainly does occur, but not so 
commonly, we think, as some writers describe. Swelling of the inguinal 
glands is considered by Mr. Barwell to indicate osteitis. We would go even 
farther, and say that when considerable it often indicates disease of the 
pelvis rather than of the femur. It is common to find some enlargement of 
inguinal glands in tuberculous children, but we think they seldom suppurate 
unless the pelvis is diseased. The condition of the iliac glands will be 
noticed again. 

Musculo,} Spasm. — Spasm of the muscles around the hip is, as in the 
case of other joints, an almost universal condition — quite universal, if we 
except those cases of osteomyelitis where the inflammation is as yet limited 
to the bone, and the few cases where the joint is slowly and painlessly dis- 
organised — cases already alluded to under the section of pain. 

The spasm is due, as is well known, to two causes : reflex spasm from 
irritation of the terminal nerve filaments supplying the articulation, the 
stimulus being reflected in accordance with Hilton's laws to the muscles 
moving that joint — BarwelFs 'joint sense;' and secondly, a voluntary con- 
traction of the muscles to prevent movement of the painful surfaces the one 
upon the other. 

It is well known to what the particular position of the joint in disease is 
•due ; flexion and abduction, as long as it remains a closed cavity, is the 
position of least tension, and therefore of least pain ; the aggregate mass of 
flexors, too, is stronger than the extensors here as elsewhere, so that flexion 
is the position of rest. 

The rigidity of the spasm is very great indeed, so much so that in many 
cases, without painful manipulation, it is impossible to say from mere 
physical examination that the joint is not anchylosed. In most cases, how- 
ever, there is a certain limited range of movement allowed through, perhaps, 
io° in the middle of flexion, and in many cases a considerably larger 
range, while in some it is only in extreme flexion and extension that spasm 
exists. 

Nocturnal spasm has already been alluded to under the section of Pain. 

Fixation or Rigidity. — Fixation of the joint, apart from muscular spasm, 
may depend upon any one of three causes, but can only exist in the second 
or third stage of the disease, or as a result of quiescent or cured disease. 
The causes are adhesions within or around the joint, matting together ot 
muscles so that their power is lost, or bony anchylosis. Chloroform at once 



646 Hip Disease 

when, of course, it will disappear ; or to adhesion or permanent muscular 
contracture, when it can generally be sufficiently overcome to show that 
there is no bony union of the parts. 



iM 







Fig. 137. — Showing the extreme Lordosis produced by partial correction of the deformity 
in a case where rectangular flexion existed. 

Grating or Crepitation. — Grating felt on movement of the hip joint can be 
produced by one cause only, the presence of exposed bone. This may be 
due either to erosion of cartilage allowing the bare head of the femur to grate 
against bare acetabulum, or to sequestra grating against one another, or to 
the upper end of the femur rubbing against its own bare and detached head. 
It is, therefore, where it can be felt, an absolute and pathognomonic indica- 
tion of the presence of dead or carious bone. But it must be remembered 
that it can usually only be obtained under an anaesthetic, when free move- 
ment without pain can be procured. 

Abscess. — The vast majority of cases of hip disease, unless seen in the 
early stage and adequately treated, go on to suppuration. A certain number 
of cases get well by the process of removal of the inflamed end of the bone 
without suppuration — a caries sicca ; but the greater number by far go on to 
the formation of pus. Yet of this number by no means all develop abscesses 
which open and discharge externally. Suppuration within the cavity of the 
joint takes place and even bursts the capsule, and yet, by absorption of the 
fluid and removal more slowly of the solid elements, the swelling caused by 
the abscess may disappear and the case recover. Still we are convinced 
that nearly every case of chronic disease of the hip, if the joint were examined;, 
would at a certain period of its course be found to contain pus or puriform 
liquid. 

When the joint cavity suppurates the pus may take very various courses 
after it has burst from the joint, but usually it issues at the posterior part, 
sometimes on the inner, sometimes on the outer side. It may then pass 
forward beneath the rectus femoris and point at the anterior border of the 
tensor vaginas femoris ; it may travel down the thigh and point at a lower 
part of the edge of this muscle ; it may gravitate backward and open at the 
upper or posterior border of the great trochanter, or, farther still, at the 
lower border of the gluteus maximus ; it may reach to the perinseum, extend 
along the adductor tendons, and come to the surface at the inner side of the 
thigh ; or, again, it may pierce the skin just at the inner angle of the fold of 
the groin between the scrotum or labium and the thigh. It may travel up 
the sheath of the psoas and point above Poupart's ligament, or, travelling 
over the brim of the pelvis, may then gravitate downwards and burst into the 
rectum or the ischio-rectal fossa, or escape through the sciatic notch. We 
have records of two cases where pus was discharged through the rectum, and 



Wasting — Outline 647 

we are inclined to think it is commoner than is supposed, and that the dis- 
appearance of abscesses about the joint is sometimes to be thus accounted 
for. A bad result does not necessarily follow, and some cases are probably 
glandular abscesses not directly connected with the joint ; in other instances 
fecal matter has been discharged into the joint. 

Abscesses in the neighbourhood of the hip not due to disease of that joint 
must be carefully distinguished from those which either directly communicate 
with the joint cavity or result from the breaking down of tubercular matter 
in the walls of the articulation. 

From the cases we have watched we think the conclusion may be drawn 
that when an abscess points on the front of the limb, above a line drawn 
through the upper border of the great trochanter, there is disease of the 
pelvis, and this is the more certain the higher and the more internal the 
opening. Abscess pointing between the scrotum or labium and the thigh we 
always look upon as of serious import, indicating pelvic caries. The peculiar 
conical projection to be felt on pressure above Poupart's ligament, as pointed 
out by Barwell, is rather due, in our opinion, to enlargement of the iliac glands 
than to periosteal pelvic thickening in the great majority of cases ; like 
thickening to be felt by rectal examination at the sight of the acetabulum on 
the inner wall of the pelvis, it is to be looked upon as a grave sign and one 
pointing to marked pelvic disease. 

Wasting of Limb. — Muscular wasting of the affected limb is an early 
and prominent condition in hip disease — so early and so rapid that it is, and 
with good reason, ascribed to the result of trophic nerve changes rather than 
to mere disuse. The limb in later stages assumes a peculiar bulbous look, 
the thigh and leg are small, thin, and weak, while the hip itself is rounded, 
swollen, and distended as compared with the opposite side, and coldness 
and venous congestion are commonly present, often with oedema of the foot 
from venous or lymphatic obstruction. The bone, too, undergoes a great 
amount of atrophy, the denser layer is thinned, and the spaces of the cancel- 
lous tissue enlarged, so that the bone becomes diminished both in diameter 
and strength. Such is the condition which has in several cases led to frac- 
ture of the bone in attempts at thrusting the upper extremity out of the 
wound in the operation of excision, and this is a fact to be remembered in 
the forcible straightening of the limb. 

Arrest of growth under such circumstances is to be expected, and does 
occur, but to a much less extent than would be imagined, as will be seen in 
the section on Results of Excision. 

Outli?ie of Region of Hip.— -Two points are always described in con- 
nection with disease of the hip as being characteristic of it— loss of the fold 
of the groin, and flattening and widening of the buttock with lowering and 
partial obliteration of its fold. These conditions are worth noting, although 
they are not always present, nor always characteristic of hip disease when 
they are present. The fold of the groin is most completely obliterated when 
the limb is abducted and rotated out, especially if there is also swelling o\ 
the front of the joint or glandular enlargement. On the other hand, the 
fold is exaggerated in adduction and rotation inwards ; in this position in 
girls the labium will be compressed, flattened, and partially or entirely 
hidden. 



6 4 8 



Hip Disease 



The rima naiium is inclined upwards and towards the diseased side, 
which is simply the appearance produced by lowering of the buttock in the 
second stage ; in the third it of course takes the opposite direction. 

Dislocation and Shorte7iing. — The older writers on hip disease spoke 
of dislocation as one of the common results of the destruction of the joint. 
Probably they were misled, in the absence of actual dissection, by the 
shortening, adduction, and inversion of the limb which occur in the third 
stage. 

As a matter of fact it is probable that without injury true dislocation of 
the head of the femur out of the acetabulum very rarely occurs. Several 
conditions may exist and give rise to the appearance of dislocation, the 
most common being destruction of the head of the femur ; the truncated 




Fig. 138. — Shows the position assumed in the 
second stage of hip disease. Flexion, abduc- 
tion, rotation outwards, apparent lengthen- 
ing. Right hip disease. 




Fig. 139. — A side view of fig 



upper end of the bone is then drawn upwards by the muscles attached to 
the trochanters, so that the upper border of the great trochanter rises above 
Nelaton's line ; here, as the head of the bone no longer exists, true disloca- 
tion can hardly be said to have occurred. Occasionally, however, true dis- 
location of the head of the femur on to the dorsum does occur — we have met 
with several instances of it. 

Apparent lengthening of the limb is due to a lowering and throwing for- 
ward of the pelvis on the affected side ; apparent shortening, on the other 
hand, to the pelvis being raised and thrown behind the sound side. Or, to 
take the same fact in another way, the apparently lengthened limb is flexed 
and abducted, the apparently shortened limb is flexed and adducted, the 



Diagnosis 649 

two conditions being usually, but not always, associated with rotation out- 
ward and inward respectively. 

Taking the usual classification of the course of the disease into three 
stages, the position assumed successively by the limb will be — in the first 
stage, flexion to a variable degree, with or without slight abduction, and 
possibly rotation outward ; in the second stage, flexion, usually well marked, 
with abduction usually, and rotation outward, producing apparent lengthen- 
ing — sometimes, however, there is adduction, and sometimes mere flexion, 
with no rotation, or with rotation inward ; in the third stage there is always 
flexion, and most commonly adduction and rotation inward, with apparent 
or real shortening, but there may be abduction and rotation outward. Thus 
position, though a valuable, is not an absolute guide, and requires to be 
checked by the other symptoms present. 

Diag7tosis. — The diagnosis of disease of the hip is as difficult in some 
cases as it is easy in others. In well-marked cases where the disease is 
advanced it usually is quite readily diagnosed, while, on the other hand, few 
diseases are so closely simulated by a large number of other affections as 
disease of the hip, and the variety of symptoms that it presents is in itself a 
fruitful source of mistake. It will, perhaps, most conduce to a clear under- 
standing of the subject if we first tabulate the diseases for which hip disease 
is most likely to be mistaken. 

1. Acute rheumatism. 

2. Bursitis of the psoas or one of the gluteal bursas. 

3. Ostitis or periostitis of the great trochanter. 

4. Periostitis of the upper end of the femur. 

5. Sacro-iliac disease. 

6. Psoas abscess. 

7. Iliac abscess. 

8. Gluteal abscess, traumatic or spinal. 

9. Abscess connected with disease of the pelvis. 

10. Perityphlitic abscess, suppuration around the sigmoid flexure of the 
colon, pelvic glandular abscess, or chronic adenitis, or possibly renal disease. 

11. Superficial abscess, glandular or other, and deep abscess around the 
joint. 

12. Infantile paralysis. 

13. Syphilitic synovitis or telostitis. 

14. Hysteria. 

1 5. ' Congenital dislocation ' of the hip, or other congenital conditions. 

16. Rickets. 

17. Disease of the knee. 

Of these diseases only a few of the more important need be selected 
here. Inflammation of the gluteal bursa:, of which that between the gluteus 
maximus and the great trochanter is the most commonly affected, may 
simulate hip disease. In this case a large gluteal abscess may be mistaken 
for abscess connected with the joint, or if the abscess has burst the long 
track left may lead upwards, and be indistinguishable from one com- 
municating with the joint ; the absence of shortening, of adduction, or oi 
grating on movement of the joint, which will also move freely through a 
certain range, absence of pain on jarring or pressure, and of fullness in front 
of and behind the joint, are the diagnostic points. 



650 Hip Disease 

Disease of the great trochanter is more difficult to distinguish, and it must 
be remembered that inflammation may extend from the shaft to the joint ; but, 
although in trochanteric disease sinuses may exist in the same positions as 
those in which they are found in morbus coxae, the smoothness and freedom 
from grating, as well as the wide range of mobility of the joint, will serve to 
distinguish between the two ; other abscesses in the neighbourhood of the 
joint are recognised by their history, which is usually too short for chronic 
hip disease, and not acute enough or sufficiently severe for acute joint in- 
flammation. They are also recognisable by the freedom and smoothness of 
the movements of the joint through a certain range, even though that range 
may be a limited one. Absence of pain and tenderness in some part of the 
joint circumference will be contributory evidence. 

Infantile paralysis simulates hip disease in the lameness to which it 
gives rise, but is distinguished from it by the absence of pain and swelling., 
and especially by freedom of mobility, and by an amount of wasting and 
coldness of the limb disproportionate to the other symptoms, as well as by 
the history of the disease ; it is, however, worth noting that in the ' British 
Medical Journal' for 1877 Mr. Savory records a case of acute hip disease in 
a leg affected by infantile paralysis. 

Syphilitic disease is distinguished by other evidences of syphilis, by the 
slight tendency there is to suppuration, and by its amenability to mercurial 
or iodide treatment. We have, however, seen chronic hip disease in a con- 
genitally syphilitic child. 

Sacro-iliac disease and psoas abscess may both simulate hip disease in 
regard to the position in which they give rise to pain, and as to flexion of the 
joint ; it is, however, only necessary to examine the spine and sacro-iliac 
articulations to find in most cases symptoms incompatible with disease of the 
hip alone, while in simple psoitis flexion and inward rotation are free. 

It must be remembered, at the same time, that the abscess within the 
psoas sheath, resulting from either of these diseases, may open into the hip 
joint, and so a secondary hip disease may be developed. It is not, we 
believe, very rare for psoas abscess to do so ; and, although we have only 
had one opportunity of verifying the fact post mortem, we have in several 
instances believed such to be the case. Spinal caries and hip disease may, of 
course, coexist independently of each other, and this is not rare. It is some- 
times impossible to be sure that disease of the hip does not exist where an 
iliac or psoas abscess has burrowed down and surrounds the hip joint on all 
sides ; the symptoms are then often identical, and only the discovery of 
the spinal or iliac disease can clear up the case. In other instances free 
mobility of the joint through a certain range in all directions excludes hip 
disease. Rectal examination enables us to distinguish between hip disease 
and spinal gluteal abscess, since in the latter the abscess can be felt to 
extend upwards over the brim of the pelvis. 

Abscess connected with the caecum, or sigmoid flexure, is not uncommonly 
mistaken for hip disease. Such cases closely resemble iliac abscesses from 
other causes, with the addition of symptoms indicating connection with or 
proximity to the large bowel. 1 

1 Vide paper ' On some Forms of Abdominal Abscess occurring in Children,' by 
G. A. Wright, \x\Arch. of Pediatrics, 1884; also Lancet, 1890. 



Diagnosis 651 

Congenital atrophy of the femur is not likely to be mistaken for recent 
disease, but may, perhaps, be a result of intra-uterine affection of the joint. 

One of the commoner sources of error is enlargement of the iliac or of 
the inguinal glands ; pain, lameness, flexion, and some rigidity of the joint 
are found ; on examination by deep pressure above Poupart's ligament the 
enlarged glands may be felt, and palpation is painful ; careful search, how- 
ever, will show rigidity only in extension or slightly in abduction as well, 
while flexion, adduction, and rotation are free ; there is no trochanteric 
thickening and no evidence of effusion into the joint. It must be remembered 
that the glandular enlargement may be due to hip disease itself. 

It is always well to use the 'method of exclusion' in doubtful cases, and 
to bear in mind that there is no one symptom pathognomonic of hip disease, 
but that, as in other morbid conditions, several factors have to be taken into 
account in forming a diagnosis. Free, smooth, painless mobility is perhaps 
the most satisfactory evidence of the absence of hip disease. 

To sum up the diagnostic points of hip disease. A patient who is a child, 
who walks lame, especially after a little exercise, who has thickening of the 
trochanter, some tenderness on pressure over the hip joint, and pain together 
with slight flexion and some immobility of the joint, without evidence of 
spinal or sacro-iliac disease or pain in any part higher than the hip, and in 
whom pain is increased by abduction or rotation inwards, has got disease of 
the hip. We would here lay stress upon the fact that there is not the smallest 
necessity for hurting a child in an examination for hip disease. It is true 
that pressure upon the trochanter or heel, what is expressively called by 
American surgeons ' crowding the joint surfaces together,' gives rise to pain 
in disease of the joint, but it is neither a necessary nor a pathognomonic 
sign. Night starting is a valuable, but not a constant nor always trustworthy, 
symptom. Later in the disease the problem is usually easily solved, but 
not always, for, as indicated above, disease of the trochanter or abscess 
around the joint, as well as bursitis, may resemble hip disease very closely ; 
in such cases the position and swelling of hip disease, as well as its rigidity, 
are very closely simulated, and we must rely on other points. Such condi- 
tions can, however, only be mistaken for the later stages of the disease, 
in which there will be shortening of the limb, raising of the trochanter, 
and probably grating in the joint if examination is made under chloro- 
form. It is only occasionally that we see a child in quite the first stage 
before the mischief has reached the surface of the bone ; in such case 
pain, lameness, slight flexion, and slight rigidity are the principal signs. 
Usually the patient is brought in the early second stage, when trochanteric 
blurring is found. 

Believing, as we do, that chronic hip disease in children begins invariably, 
or nearly so, as an osteomyelitis, we cannot follow Harwell's distinctions in the 
diagnosis of this condition from synovitis. We do, however, think that acute 
synovitis can be distinguished from the early stages of true hip disease by the 
greater pain on movement of the joint, with absence of trochanteric thicken- 
ing, and under chloroform free and perfect mobility in the former : there may 
be also swelling in front of the joint, but this depends upon the amount of the 
effusion. In simple traumatic synovitis the mischief immediately follows 
the injur>-, while in the bone lesion there is usually an interval oi two or 



•652 Hip Disease 

three weeks, or often months, between the accident and the onset of 
symptoms ; thus the child falls, cries for a few minutes, but is then well 
again, and in a month's time begins to limp. This evidence of the history 
is most important. Careful inquiry should always be made in every case 
for any previous trouble about the hip, since the acute symptoms may be 
grafted upon old latent disease. 

Acute osteomyelitis is readily diagnosed ; great constitutional disturbance, 
fever, and prostration, great pain, amounting to agony on the least movement, 
helplessness of the limb, rapid and extensive swelling, with venous turgidity, 
make the diagnosis easy. 

Mr. Howard Marsh, in his valuable paper in the ' British Medical Journal ' 
for 1877, gives us most useful information on the diagnosis of hip disease. 
Thus, he points out that, though flexion may be free in some cases, the 
flexed limb is carried into abduction, and not straight up towards the 
abdomen ; again, flexion may be limited in cases of gluteal, or extension in 
cases of psoas abscess, but in hip disease both are limited in their more ex- 
treme degrees, even if free in part of the range of mobility. His caution as 
to the dangers of frightening the muscles into spasm is also well worth 
remembering. In examining children it is always wise to manipulate the 
sound limb first, as this gives the child confidence that he is not going to be 
hurt, and he is less likely to voluntarily hold the joint stiff. Rectal exami- 
nation for thickening of the inner wall of the acetabulum we have occasionally 
found of value in doubtful cases, and it certainly should be employed if there 
is any suspicion of primary acetabular disease ; under such circumstances it 
may be the only way to clear up the doubt. An excellent account of it is 
given in Dhourdin's work, ' De la Coxalgie Cotyloidienne. 3 

In examining a child for suspected hip disease in an early stage the course 
of procedure should be as follows. First, the child's confidence should be 
gained, so that it will not be afraid ; next, all clothing should be removed 
and a blanket wrapped round the patient, who should be allowed to walk to 
a flat, hard couch or table covered with a rug. The position of the limb and 
the child's gait should be carefully watched. Then, with the child lying 
straight and flat upon its back, any abduction of the limb should be looked 
for, an imaginary test line passing downwards from the middle of the 
sternum through the umbilicus and pubes being taken as the guide. The 
length of the two limbs, taking into account the pelvic tilting, is now to be 
compared. The next point is to notice whether the affected limb is put 
down flat upon the table — i.e. whether the thigh and knee are flexed or the 
back arched (lordosis) — also whether there is any wasting of the limb. 
The surgeon should then take the sound limb gently in the hand and fully 
flex it, looking for any movement of the pelvis ; as soon as the full degree of 
flexion has been ascertained the affected limb should be very gently raised 
and its range of mobility compared with that of the sound side, a finger 
being kept on the anterior superior spine of the ilium to feel for any tilting 
of the pelvis. Should there be any lordosis due to fixed flexion of the hip, 
this will disappear as the limb is raised and be increased by extending the 
leg. The finger, or better the thumb, should then be gently pressed into 
each iliac fossa to feel for swelling there, due to enlarged glands or the 
presence of an abscess ; fullness below Poupart's ligament should also be 



Prognosis 653 

looked for. If no restriction of movement has been found, abduction, 
adduction, and rotation should be tested and the two sides compared. 

The child should next turn over and lie on its face— it is generally better 
to allow it to turn in its own way ; the shape of the buttock, the thickness 
of the trochanters, the gluteal fold, and rima natium are now inspected and 
the range of extension further investigated. The spine and sacro-iliac joints 
should be examined at this stage, swelling of the knee joint and thickening 
of the shaft of the femur having been previously searched for. If there is 
still a doubt, a finger should be passed into the rectum, and the inner wall 
of the pelvis examined for thickening, or abscess, or enlarged glands ; for 
this proceeding it is often necessary to give an anaesthetic. Where disease 
begins in the acetabulum, but has not yet reached the cavity of the joint, pain 
and slight lameness may be the only obvious symptoms. Mobility of the 
joint may be almost perfect. In such cases the presence of thickening felt 
per rectum as well as by deep pressure in the iliac fossa, is all-important as a 
means of diagnosis. 

No one symptom alone is sufficient for a diagnosis in early stages, but 
limitation of movement to some extent, and trochanteric thickening, are 
perhaps the two most valuable signs of joint disease. 

We would here deprecate the use of any of the means of diagnosis which 
necessitate giving pain to the patient. The presence of disease is re- 
cognisable by the painless mode of examination in all cases where it can be 
made out at all. In all cases examination for hip disease should be made 
with the child completely stripped, and lying on a. flat hard couch or table. 

Prognosis. — As regards the prognosis and the results of affections of the 
hip joint when treated by means other than operation, it is necessary to dis- 
tinguish clearly between the two morbid conditions of acute synovitis and 
osteomyelitis, acute or chronic : the former recover perfectly with freely 
movable joints under proper treatment, and show no after ill effects, though 
the treatment required is usually longer than that for other joints. On the 
other hand, cases of true hip disease, unless effectually treated in the early 
stage, very rarely recover without entire destruction of the upper epiphysis 
of the femur, usually accompanied by abscess, and always result in shorten- 
ing with more or less deformity, and a very large majority die before reaching 
adult life. 

Even when tuberculous disease of the hip seems to have subsided, re- 
lapses are exceedingly common after some slight injury or intercurrent 
illness. It is important, however, to distinguish between relapses due to a 
fresh lighting up of disease and the presence of an abscess the result of irri- 
tation by some quiescent local product of former inflammation — the residual 
abscess of Paget. 

As to the usefulness of the limb after recovery from hip disease without 
operation, more or less shortening is to be expected in all cases, cither as a 
result of malposition, retraction of the femur upon the dorsum ilii, actual 
destruction of bone, or arrest of growth of the femur: the last is the least 
important factor, since increase of length in the femur takes place almost 
entirely at the lower end, and what shortening there is is due rather to general 
arrest of growth of the limb than to destruction of the upper growing line. 
In private practice, where hip disease is seen early and treated more 



654 Hip Disease 

effectually than it can bs in hospital practice, the prospect of recovery is 
much better, though even here a perfect result is rare ; it will, however, be 
obtained under exceptionally favourable conditions. A movable joint may 
be obtained where the disease comes under treatment in its early stage, or 
even after destruction of the joint there maybe a certain amount of mobility, 
though this is less frequent than it is after excision. 

In fatal cases of hip disease death is generally due to tuberculosis or 
exhaustion, with hectic or lardaceous disease ; sometimes an intercurrent 
exanthem proves fatal. Hence it is seen the prognosis depends very 
largely upon whether early and efficient treatment, of which that by 
Thomas's splint is undoubtedly the best, can be obtained. The cases least 
likely to do well without operation are those in which there is a great amount 
•of thickening, and those in which, in spite of fixation, pain continues, while 
under any circumstances the prognosis is bad if there is extensive pelvic 
caries (not necrosis). 

Treatment. — First, the ideal treatment consists in seeing the case early, 
keeping the child in bed until by simple extension or a Bryant's splint the 
limb is straightened ; then a Thomas's splint should be applied, 1 and the 
child allowed to get up and about, out of doors, by the seaside. Good 
food, cod-liver oil and iron, with occasional administrations of rhubarb and 
soda if any dyspeptic troubles appear, comprise the rest of the management. 
'Two years should be the time given for rigid treatment ; after this the 



Fig. 140. — Bryant's Splint. We have had sliding pieces made to fill up the interruptions when 
required ; this is seen in the figure. 

splint may be gradually laid aside, and the child allowed to go about with 
.a patten and crutches for a few weeks ; if still there is no sign of disease, 
walking upon the affected limb may be gradually permitted. During the 
time of treatment the greatest care must be taken not to allow the foot of the 
affected side to touch the ground, and to avoid all falls or strains of the joint. 

American surgeons use to a great extent ' traction splints ' of various 
forms, in which, while the patient gets about more or less, extension is kept up. 2 
The weak point in most of these appliances is that the joint is not fixed. 

In hospital practice the nearest approach to the above lines of treatment 
should of course be carried out, but if there is progressive disease, and the 
management is unsatisfactory, excision should be performed at the first sign 
of external abscess, or before if the symptoms are acute. In either case the 
presence of progressive disease in spite of treatment, with an abscess other 
than a residual one, or sinuses, or great thickening, indicates immediate 
excision. If sinuses exist with receding disease, diminishing discharge, and 

1 Or the limb may be straightened by means of the Thomas's splint. 

2 For a good recent account of these splints we must refer to Dr. Lovett's work on 
Disease of the Hip, 1892. 



Treatment by Extension 



655 



puckering in of cicatrices, or if with an abscess the mischief is quite quiescent 
or receding, non-operative treatment should be adopted for a time, if it can 
be thoroughly carried out ; if not, or if no progress is made in a few weeks, 
the diseased part should be removed. 

In applying extension by weight it should be made an invariable rule to 
make traction from the condyles of the femur, and not from below the 
knee. A case is on record in which prolonged extension applied below the 
knee resulted in separation of the upper epiphysis of the tibia. It is also 
objectionable in that it throws strain upon the knee joint, and is more apt to 
slip off. The strapping should always, if possible, be applied for some hours 
before the weight is attached, in order that the plaster may get set, and not 
be dragged off by the weight. The strapping (of which Leslie's brown 
holland is the best) should be kept from the skin by a strip of lint or flannel 
bandage, or part of a stocking, to protect the sharp edge of the tibia and 
the prominences of the joint from pressure (fig. 141). 




Fig. 141. — Shows extension by a weight applied above the knee, with a long splint on the sound side. 
Also the simple plan of keeping the child from sitting up by means of the board running behind 
the shoulders and fastened to the side of the bed. The shoulders are fastened to this board, and 
the arms are left free below the elbow. The bed on which the child lies is somewhat too soft. 



We have found that too great extension may be a cause of painful 
spasms, and it is well to bear this in mind, that too great extending force and 
too little are alike inefficient. In cases where treatment without operation 
is carried out, as for instance where adhesions, the result of old inflam- 
mation, exist, or muscular contracture has taken place, the deformity may 
be remedied in many instances by the ordinary extension apparatus, by a 
weight, or by Bryant's splint. In other cases, where simple extension is 
inefficient, or too tedious, it may be necessary to forcibly straighten the 
limb under chloroform, and then fix it by splints in its new position. The 
advisability of forcible straightening is a somewhat disputed point and is 
not in all cases free from risk, not only of laceration of important structures, 
but of setting up fresh inflammation in the joint or what remains o\ it. 

Mr. Howard Marsh, 1 and in [836 Sir Benjamin Brodie, advised that 
the extension should be made in the axis of the misplaced limb, and that 
1 Brit. Med. Jour, July 1876, 



656 Hip Disease 

the direction should be altered as the limb regains its normal position. We 
do not think this a matter of great importance. If it is desired to carry out 
this plan, probably Hodgens splint for fracture of the thigh would be the 
most efficient apparatus. 

It is sometimes a matter of difficulty to remedy the malposition of the 
limb in cases of fixation in combined flexion and adduction or abduction. 
Here, where possible, gradual reduction by a Bryant's splint is the best 
treatment (fig. 140) ; failing this — and it cannot be always used— a long splint 
on one side, with a weight to the mal-placed side, should be tried (fig. 141) ; 





Fig. 143. — Thomas's Hip Splint adjusted 
for a case with no deformity. 



Fig. 142. — Thomas's Hip Splint, applied. Slightly altered 
from Mr. Thomas's work on the ' Hip. Knee, and Ankle.' 



and, failing this, careful straightening under chloroform. Where there is 
much abduction Volkmann applies a weight to each leg, the heavier one 
being attached to the sound side. (A. H. Tubby.) These methods are, we 
think, better than remedying the deformity by weights applied laterally. In 
more acute cases, where the deformity is mainly due to spasm, gradual 
extension is best, but by some means the limb must be got as quickly as 
possible into good position. 

Thomas's apparatus is a very valuable appliance, and is undoubtedly the 
best splint we have for patients able to be up (figs. 142 and 143). The splint 
requires careful attention to detail, both in fitting it and in management ; it 
is of use, first, in the early stages of disease, where it is possible to give the 
child the chance of long-continued and perfect rest, with general hygienic 
measures : and, secondly, after excision, to keep the limb quiet for a time 



Excision of tJie Hip 657 

until the parts are sufficiently consolidated to allow of movement being 
begun. We have habitually used it for many years. 

The question of when to excise a hip joint is no doubt a difficult one, but 
the conclusion we have come to is this. Treatment, short of excision, when 
once suppuration occurs, is, if the disease is progressing, useful only as a 
palliative. Our opinion, bearing in mind Mr. Holmes's valuable remarks 
on the social circumstances of these patients, is that where there is an 
abscess outside the joint, or, without this, great trochanteric thickening, or 
much pain that does not yield to treatment by rest, excision ought to be 
performed. In private practice cases are usually seen in the first or early 
second stage, and it is possible to ensure that the Thomas's splint shall be 
kept on and no strain thrown upon the joint : hence recovery without opera- 
tion is the rule. While fully aware that abscesses disappear and tuberculous 
lesions cicatrise under favourable circumstances, we think that in the case of 
the hip delay is unwise among the hospital class, with whom it is as yet 
impossible to deal on the same lines as with the well-to-do. In almost every 
instance we have found much more extensive disease than might be expected 
from the external evidence, unless the pathology of the affection is borne 
in mind, and we believe that, once this chronic osteomyelitis is fully 
established, nothing short of excision can, in the majority of hospital cases, 
prevent the ultimate progress of the disease to abscess, and too often to 
gradual exhaustion of the patient by pain and discharge. Nature, of course, 
in many cases will, unaided, get rid of the dead bone by slow and tedious 
processes, but the number of children who can survive the process of elimi- 
nation is very small, while the mortality after early excision is not great, and 
the failures are mainly in those instances where the operation has been put 
off till too late. Where actual necrosis, or caries of the head of the femur, 
with destruction of bone and cartilage, and often sequestra of varying size in 
the acetabulum, or at least caries of it, is known to exist, we think few advo- 
cates of non-operative treatment will be found. It is then, as Mr. Bryant 
points out, to be looked upon rather as an ordinary operation for necrosed 
bone than anything more formidable ; and that this is the state of the joint 
even in cases often spoken of as those of early disease is the fact upon 
which we should like to lay stress. 

As soon, then, as there is any evidence of external abscess, excision 
should certainly be performed, and still better results will, we believe, be 
obtained by operating even before the pus has escaped from the articulation. 
It is necessary of course to distinguish sharply between abscess the result of 
progressive disease and residual abscess ; it is in the former that immediate 
excision is called for. Where the disease is quiescent, abscesses may well 
be dealt with by the method already described, of thorough cleaning out and 
closure after injection of iodoform emulsion. We are not disposed to think 
that mere injection of iodoform into tubercular joints without removal of the 
original focus of disease will be successful to any great extent. It is 
undoubtedly useful in some cases to deal with the abscess first, and, when 
that has healed, to remove the diseased bone by a second operation under 
more favourable conditions. The operation of excision is discredited because 
it is put off until disease is so far advanced that no mode of treatment can 
have more than a small proportion of good results ; while timely excision 

v l" 



658 Hip Disease 

cuts short the disease, saves pain, lessens the time of treatment, and gives a 
better limb. 

Modes of Excision. — Various incisions for removal of the upper end of 
the femur have been advocated. Of these the incision over the middle of 
the trochanter and slightly concave forward is the one we usually adopt. 
We see no advantage in most of the others over the one extending downwards 
for about three inches, more or less according to age and the extent of the 
disease, along the middle of the trochanter. Where however it is proposed 
to remove a large part of the pelvic wall, a flap operation is desirable, and 
we have recently frequently used it ; the flap incision has the advantage of 
freely exposing the diseased area and allowing thorough cleaning of the soft 
parts, and by chiselling off and turning up the trochanter with its muscles 
attached the power to move the limb subsequently is likely to be greater. 

Next, if a flap is not made, the soft parts should be divided vertically 
above the trochanter and the capsule opened freely, if this has not been 
done by the first incision. The joint should then be explored with the 
finger. 

The next step is to separate the soft tissues from the bone on the inner 
side, stripping back the periosteum as far as it exists as such. The finger 
should then be used to pass round the bone and feel that the upper end 
is free ; next, still using the finger as a guard at the inner side of the bone, 
the femur should be sawn through just below the trochanteric margin with a 
keyhole- or finger-saw. Some part of the trochanteric epiphysis is usually 
left behind. The upper extremity of the bone is then readily prised out with 
the finger or raspatory. The acetabulum should be then examined and any 
sequestra removed. If there is a large carious surface it may be gouged or 
scraped with a Volkmann's spoon or left alone. It is well to remove any 
rough or semi-necrosed bone, but we doubt the possibility of being able to 
remove all the disease without greatly adding to the severity of the operation 
where there is extensive inflammation without necrosis, nor is such treatment 
desirable. 

The upper end of the femur should be examined to see if the whole 
disease has been removed ; if not, a further section should be made, and 
this may -be carried a considerable distance down the shafts six inches have 
been removed with a good result, and but little shortening, by an American 
surgeon. 

Here it is well to point out the danger of the practice of thrusting the 
head of the femur forcibly out of the wound before sawing it through, instead 
of dividing it in situ. Several cases of fracture of the shaft of the atrophied 
fatty bone have occurred. An additional objection to this practice is the 
ease with which the periosteum may be thus stripped off the inner aspect of 
the shaft, and so necrosis may occur. 

The operation is much more easily and safely done in the way described, 
and involves less violence to and less division of the soft parts. The finger 
is quite as good a guide as the eye to the condition of the bone. 

Usually no vessels require ligatures, though there is sometimes free 
oozing of blood. If the wound can be made aseptic, it should be carefully 
cleaned and closed by sutures after injection of iodoform emulsion ; if the 
case is one with old-standing sinuses, we prefer to leave it quite open, and in 






Excision of the Hip 659 

that case a large drainage tube should be passed deep into the cavity of the 
joint. Any sinuses or abscess cavities should then be thoroughly scraped 
out and well cleaned before applying the dressing. It will often be found 
that a distinct membranous layer of lymph lines the cavity of the articulation, 
but there is rarely anything like the thickness of granulation tissue so often 
seen in the knee and other joints. It is well to remove any masses of pulpy 
granulations should they exist, but anything like the elaborate dissection 
required in erasion of the knee is impracticable. 

There is not, we think, any great advantage in removing only the head 
•of the bone and leaving the trochanter. A section through the neck will 
often leave unhealthy bone behind. In many cases the head of the 
femur is so far destroyed that it would be impossible to do less than take 
away the trochanter, while the trochanter if left in cases that require drain- 
age tends to block up the orifice of the wound and prevents the free escape 
•of discharge and debris of bone, and thus interferes with one of the main 
objects of the operation. The Clinical Society's Committee advised that 
the trochanter should be left unless diseased, or unless there is extensive 
pelvic disease, and where the flap operation is employed it must be left. 

Where intrapelvic abscess exists the acetabulum should be perforated. 
Examination per rectum enables the diagnosis to be made if this condition 
Is suspected. 

As regards the use of antiseptics, they should, of course, be used in all 
cases. The most convenient form of dressing afterwards is a thick pad of 
wood-wool wadding, over a thin layer of wet gauze. Iodoform should be 
freely dusted into the wound before applying the dressings, and iodoform 
emulsion injected into the recesses of the wound after thoroughly cleaning it 
out. 

Messrs. Barker and Pollard, in December 1 888, brought before the Medical 
and Chirurgical Society of London a new method of managing the operation of 
excision of the hip. The method consists in clearing away all disease of the 
soft parts by scraping or excision ; scraping out abscess cavities, and by 
means of thorough and careful asepticism getting the wound clean. The 
novelty is in their mode of carefully drying out the wound and closing it en- 
tirely after removal of all tuberculous . material as far as possible, so that 
primary union is obtained. Messrs. Barker and Pollard showed cases in 
which this result had been obtained, and we have since then followed their 
plan in its main features with success. There is no doubt this is a valuable 
improvement, but it is applicable to cases of early excision chiefly, or onjy, 
and experience shows that even so there is danger of relapse (p. 663). For 
further details we must refer to the ' Medico- Chir. Transactions,' 188S : but 
-vvc may reprint here Mr. Pollard's abstract of the essentials of the method : — 

1. The whole of the tubercular growth must be removed. 

2. Perfect asepsis must be assured. 

3. Bleeding must be checked and the wound made as dry as possible. 

4. Oozing must be checked by the even, elastic support of a wool dressing 
and a moderately tight bandage. 

5. Absolute rest of the part must be maintained during the process o\ 
healing. 

Following Mr. Howse, we prefer to have the extension put on before the 

U L 2 



66o 



Hip Disease 



operation, so that the weights, or, better, Bryant's splint, can be applied at 
once before the patient is put to bed. The shock of the operation is often 
somewhat severe, but usually soon passes off under the use of opium and 
stimulants. Rarely, however, much more severe and prolonged shock 
occurs. 

The subsequent management of the case requires some special remarks. 
It is exceedingly difficult to keep the wound aseptic in cases where sinuses 
have previously existed or where there is widespread suppuration. It is r 
however, a great gain if the wounds can be kept 
sweet even for a time, and with present methods 
(1895) primary union after excision may be 
expected in a large proportion of cases. Vide 
Note, p. 663. 

The after-treatment of cases of excision 
simply consists in dressing and in keeping the- 
limb quiet and in good position. This may be 
done by various means, of which the best are 
simple extension by a weight (the weight may 
usually be reckoned at one pound for each year 
of the child's age from two to six ; six pounds is 
generally enough up to twelve years of age, after 
which more may be added), with or without a 
long splint on the opposite side, and a Bryant's 
double splint, which has many advantages in 
securing 'parallelism of the two limbs,' and in the 
ease and comfort with which the patient can be 
moved. It is an invaluable apparatus, and we 
now almost invariably use it. 

The sooner excision cases are got up and. 
about, the better : some cases may leave their 
beds in three weeks ; others, of course, are much 
longer in getting up, the difference depending 
mainly upon the state of the disease at the time 
of operation. 

The period of convalescence after excision 
varies from the time mentioned to two years, 
while in some cases sinuses may remain open much longer if pelvic- 
disease exists. We keep our patients usually in a Thomas's splint for 
from at least three to six months after excision ; after this the child, if 
old enough, should get about with a patten and crutches, allowing the limb 
to swing, and only after a year or more should he be allowed to gradually 
bear weight upon the leg. If, however, excision is done early, the limb is fit 
for walking sooner, sometimes in five or six months. If the affected leg is 
allowed to touch the ground too soon, it becomes pushed up upon the dorsum 
ilii, and much shortening results. On the other hand, if the limb is fixed 
too long, it becomes stiff. A very large proportion of cases of excision in 
the later stages of the disease remain with sinuses, but often these produce 
no ill result except the trouble of dressing them : a certain number may be 
got to close by scraping, cautery, &c. ; others are very intractable. In a 




ig. 144. — From a photograph 
showing a good average result 
after excision, when the leg has 
been walked upon, and the 
stump of the femur is thrust 
up upon the dorsum ilii. 



Summary 66 1 

certain number of cases the wound re-opens after having healed ; this is 
undoubtedly common, but is due to over-use, neglect, or violence, and with 
ordinary care and frequently repeated scrapings with closure of the wound 
after excision of tuberculous tracks and edges of skin, the wounds usually 
again close. 

It is interesting and important to note that in measuring the amount of 
shortening after excision the real shortening — as measured from the upper 
•end of the femur to the malleolus on each side — is often trifling, and some- 
times there is none, while the practical shortening as measured from the 
pelvis to the malleolus is considerable. Though some shortening will neces- 
sarily result, any large amount is due to weight being borne upon the limb 
prematurely. It has already been pointed out that growth in length of the 
femur takes place almost entirely at its lower epiphysial line ; hence the loss 
of length or true shortening is only the distance from the line of section to 
the top of the head, coupled with such arrest of growth as may result from 
impaired nutrition, this last being, of course, a very inconstant quantity. 
Oilier estimates that during the first four years of life growth takes place about 
equally at each end of the femur ; after that time the lower end grows more 
rapidly. 

The primary objects of the operation of excision of the hip are to save 
life and relieve pain ; the next most important question is that of the useful- 
ness of the limb and of the condition of the 'joint' after the operation. One 
of two results must occur after excision : either a freely movable limb, or one 
with varying degrees of stiffness, from some mobility to bony anchylosis. 
Bony anchylosis after excision is very rare. Close fibrous union, so that but 
little mobility remains, is very common ; movement through from 30 to 50 
is perhaps the commonest result, and a smaller number have complete 
mobility. 

It is not possible to estimate in figures the results to be expected from 
excision ; for details we must refer to the monograph mentioned at the 
beginning of the chapter. 

Whether, then, we consider the pathology of the disease, the actual local 
condition, the relief of pain, the preservation of life, the duration of illness, 
the condition of the limb and its usefulness, or the dangers of secondaiy 
disease, on every ground, in our opinion, excision is the best course under 
the circumstances already stated. 

Conclusions. — 1. The hip joint in childhood is commonly subject to two 
.affections : (a) simple synovitis ; (d) tubercular disease. 

2. Simple synovitis is usually traumatic, very rarely suppurates, is amen- 
able to ordinary treatment, and as a rule leaves behind no bad results. 

3. Tubercular disease, or common ' hip disease,' affects primarily the 
upper end of the femur, or occasionally the acetabulum, and produces necrosis 
or extensive caries. 

4. In the early stage of hip disease, before caseation of bone or suppura- 
tion has taken place, proper treatment will, in a fair proportion of ca>e>. 
result in recovery with a nearly perfect limb. 

5. As soon as suppuration occurs, it is certain that recover)' will not 
take place without destruction of the upper epiphysis ot the femur more or 
less completely. 



662 Hip Disease 

6. The process of removal of the diseased bone without operation is so 
slow, so exhausting, and so uncertain, that it should be reserved for those 
cases where time and care can be fully devoted to it. 

7. Unless absolute rest and treatment for two years can be ensured, ex* 
cision of the upper end of the femur should be performed as soon as suppu- 
ration or other evidence of necrosis is present. 

8. A case of hip disease, seen before suppuration has occurred, is best 
treated by the use of a Thomas's splint with or without previous straightening 
by extension. 

9. Excision of the hip cuts short the disease, relieves pain, and gives a 
better limb than the average result obtained without operation in cases of 
equal severity. 

10. Excision should be looked upon as an ordinary operation for necrosis,, 
and the operation itself is not necessarily attended by a higher mortality than 
sequestrotomy elsewhere. 

11. Excision in old pelvic disease, or where the health is broken down,, 
or the patient is over fifteen years of age, should be rejected in favour of 
amputation. 

12. The presence of a sinus after operation, unless there is much dis- 
charge or evidence of extensive pelvic disease, does not imply failure of the 
operation. 

13. The presence of an abscess after a long period of quiescence (resi- 
dual abscess), without other evidence of relapse, is not to be looked upon as 
of serious import. 

Amputation. — The question of amputation at the hip joint for disease is 
one of the highest importance. We must consider not only the unavoidable 
mortality and crippling caused by the disease, but also the interference with. 
pleasure and education entailed by long confinement indoors. Where there 
is no reasonable prospect of recovery with a useful limb, amputation must not 
be too summarily set aside. 

There is little doubt that, in cases of extensive disease where the femur 
is necrosed for a long distance and the powers of the patient are inadequate 
to repair it, in cases where descending osteomyelitis occurs, and in cases 
where profuse discharge and amyloid disease come on, amputation should 
be performed. 

In cases of more advanced amyloid disease, unless the powers of the 
child are so enfeebled that the operation will prove fatal by shock, it ought. 
also undoubtedly to be done. 

In another class of cases the question is more difficult. Where there is 
disease of the pelvis, is amputation contra-indicated if other conditions re- 
quire it ? We should answer yes, if the pelvic disease extends so widely that, 
there is no hope of removing it at all, and the condition is one of caries and 
not necrosis. Where there is caries limited to the neighbourhood of the 
acetabulum, where there is necrosis, or where there is reason to think that 
the disease in the limb is preventing repair in the pelvis, amputation should 
be performed. 

As to the question of saving life, amputation at the hip performed with 
due precautions as to haemorrhage and shock, and special care during the 
first twenty-four hours, is not a very fatal operation in children. 



Double Hip Disease 663 

We have amputated in eleven or twelve cases in children. In nearly all 
excision had been previously performed. All of these recovered well from 
the operation except one who died of haemorrhage. 

The best plan is the oval incision of Furneaux Jordan ; the excision 
wound should be utilised, and the line of section brought as far as possible 
from the anus and vulva. 

Neither the various methods of operation nor the best means of con- 
trolling bleeding are questions suited for discussion here. Elevating the 
limb before operation, and digital pressure with the help of an elastic tour- 
niquet in the early stages of the operation, are as efficient means of control- 
ling the haemorrhage as any ; in several cases we have ligatured the femoral 
or external iliac as a preliminary, and think well of this plan. 

If possible, it is, as pointed out by Mr. Shuter, well to preserve as much 
periosteum as possible, and it will be found that after excision the bone 
usually very readily separates from the periosteal sheath ; a longer, firmer, 
and more or less mobile stump may be thus obtained. 

Double Hip Disease is not a very rare condition, and we have more than 
once had cases in which the second joint has become diseased while the child 
was lying in bed for the treatment of the first joint. The management of 
these cases is that of the common condition, except that a double Thomas's 
splint is of course required. Double excision is occasionally called for, and 
we have had good results from it ; in one case the child remains sound and 
well, and is able to walk without support. 

Scissor-leg-g-ed Deformity after Hip Disease.— Mr. Lucas, Dr. Tyson 
of Folkestone, and others have recorded cases where, as a result of double 
hip disease, a peculiar ' cross-legged or scissor-legged deformity' occurs : 
both legs are adducted, the one in front of the other, and progression takes 
place entirely by movement at the knee joint. It is easy to understand the 
condition by simply walking with the knees crossed over one another. It 
occurs, according to Mr. Lucas, in cases where disease has taken place first 
in one joint, resulting in adduction, and then subsequently in the other joint. 
Other deformities may result from the same condition. 

Tubercular Embolism. — Mention must here be made of instances in which, 
after some operation upon a local tuberculous lesion, a rapid general tubercu- 
losis is set up and the child speedily dies, often of tubercular meningitis. 
There can be little doubt that in some, at least, of these cases there has been 
a direct infection of the system by the entry into the circulation of tubercular 
emboli from the wound. The only means of avoiding such catastrophes is 
to take care to remove all tuberculous material as thoroughly as possible 
and to clean the wound efficiently. Happily such an occurrence is rare, but 
we have undoubtedly met with instances of it. 

Note. — Our Senior Resident, Dr. Carruthers, has kindly gone over our records o\ 
excision of the hip from 1886 to 1893 performed by the writer. He reports that S3 operations 
have been clone, of which in 31 instances the wound was sutured without drainage. Of 
these 22 healed at once, i.e. by primary union throughout, or with the exception of small 
superficial areas ; 9 cases failed to unite at once, and 5 of the 22 which united broke 
down again after varying periods. These figures must be taken as approximate only, 
inasmuch as wounds may have reopened shortly alter discharge, and in one or two 
cases of the 83 the result is doubtful. 



664 



CHAPTER XXIX 

SPINAL DISEASE 

Caries of the Spine, Angular Curvature, and Pott's Disease, are 

terms which, as commonly used, include conditions of very varying severity 
affecting several different structures. This is so, since the spinal column is 
in each segment provided with several different articulations, and any of 
these, as well as the bone itself, may become the seat of disease. Thus the 
mischief may begin at the junction of a vertebral body and intervertebral disc, 
at the junction of a vertebral body with its epiphysis, in the centre of a body, 
or on its anterior, posterior, or lateral surfaces ; or, again, the articular pro- 
cesses, or their joints, the transverse and spinous processes, may any of 
them be separately diseased. Again, the mode of connection between the 
skull and atlas, the atlas and axis, and the sacral joints implies necessarily 
varying conditions from those found in disease of the rest of the column. 

Obviously the names given to disease of the spine are not equally 
applicable to all these affections ; disease of a spinous or an articular pro- 
cess does not give rise to angular curvature. It is, however, quite the ex- 
ception to find in children disease of the spine affecting any part except the 
bodies and intervertebral discs ; we can only call to mind two cases of dis- 
ease of a spinous process alone, one of which was the following : — 

Case. — Necrosis of the Cervical Spinous Processes. — Edward H. , age 4 years 5 months ; 
admitted July 21, 1882. Six weeks ago a hard lump was noticed at the back of the neck, 
he having, a fortnight before, fallen on the back of his head ; the swelling had gradually 
increased, but he had had neither pain nor tenderness. On admission he was well nou- 
rished ; there was a large fluctuating swelling in the middle of the back of the neck ; it was 
opened antiseptically, and about dr. iij of healthy pus escaped ; the tips of one or more 
spines were bare ; the dressing slipped the next day ; the abscess continued to discharge, 
and he was sent out on August 25 with a jurymast on and a still unhealed sinus. In January 
1883, at Out-Patients', he was nearly well : the movements of the neck were perfect and the 
thickening nearly gone, but there was still a small sinus. Subsequently a sequestrum 
consisting of the spinous process was removed, and he quite recovered. 

We have never verified a case of disease of a joint between the articular 
processes, and disease of the transverse processes is rare. The atlanto-axial 
and occipito-atlantoid joints are also very rarely affected in children in com- 
parison with caries of the bodies. 

The ordinary form of caries of the spine affecting the bodies or interverte- 
bral discs or both structures is met with in all parts of the spinal column 
from the axis to the sacrum. In a hundred cases taken at random from our 
Out-Patient papers we found eighteen cases of cervical disease, forty-one 
cases where the cervico-dorsal, upper, or mid-dorsal regions were involved, 



Pathology 



665 



thirty-three instances of lower dorsal or dorso-lumbar disease, six of lumbar 
•caries, and two of disease of the sacrum. R. W. Parker, as quoted by 
Erichsen, gives the following figures : Cervical nine, dorsal eighty-two, 
dorso-lumbar twenty-one, lumbar or lumbo-sacral thirty-seven, out of 149 
cases. These figures are of some importance, for, in the first place, no 
attempt at removal of diseased bone can be made in the dorsal region, and 
only exceptionally in the cervical part of the spine, while the treatment of 
the disease by apparatus becomes more troublesome as we ascend from the 
mid-dorsal region. Pus is more likely to point externally as lumbar or 
psoas abscess when the lower dorsal 
or lumbar vertebras are attacked, 
though it is not rare for dorsal 
abscesses to track down the spine. 
Cervical abscesses point in the pha- 
rynx or side of the neck. Lastly, 
occasionally two foci of disease exist, 
as in fig. 145. 

Pathology. — It is probable that 
caries of the spine begins nearly 
always in the body of the vertebra, 
and not in the intervertebral disc 
itself; but it is difficult to be sure of 
the relative frequency of these sites, 
for the mischief soon spreads beyond 
the limits of a vertebra in most in- 
stances. Erichsen considers the epi- 
physial lines, the front of the bodies, 
and the centre of the bodies to be in 
this order the most frequent primary 
seats of disease. Wilks and Moxon 
apparently incline to the belief that 
the bones are the primary seat of 
* scrofulous ' disease in children, while 
disease beginning in the discs is a 
separate type of lesion — at all events 
in some cases the result simply of 
injury ; probably the seat of disease 
varies. In most cases the lesion is 
an ordinary tuberculous disease of 
bone, rarefying ostitis being found in 
necrotica or more extensive necrosis exists. Although a large number of 
patients, the subject of caries of the spine, never develop external abscesses, 
.it by no means follows that no suppuration takes place ; large collections oi 
♦pus may form beneath the anterior common ligament in the dorsal region 
without ever discharging, and may, like abscesses elsewhere, dry up and 
remain as cheesy or calcareous masses. More rarely the abscess may empty 
itself into the lung or intestine ; the latter result we have seen in a case of 
lumbar caries and in sacral disease, and it is probably more common than is 
supposed, the pus in the motions being overlooked or put down to enteritis. 




-Caries of the Spine, showing 
foci of disease. 



some parts, while in others caries 



666 Spinal Disease 

In other instances caries of the spine, like caries elsewhere, may be through- 
out unattended with any pus formation (caries sicca). 

There is often a discharge of small sequestra from spinal abscesses, and 
sometimes fair-sized pieces of dead bone come away or are extracted, but 
this is not common ; as in the well-known instances of the odontoid process 
coming away entire through the pharynx. 

Pus from a lesion in one part of the spine may track downwards and give 
rise to a second focus of disease lower down, but sometimes, as in fig. 145, 
the two foci are quite independent and isolated from each other ; in the 
case from which the figure was taken the lower patch of disease developed 
first. 

In some instances disease may begin as a simple non-tuberculous 
inflammation, the result of injury as already mentioned ; this is not, however, 
common in children in our experience, since in them the disease usually 
runs the course of tuberculous lesions generally. Cases of spinal curvature, 
due to the lesions of congenital syphilis, are also described. 

Abscess. — Pus in connection with spinal caries usually burrows along 
certain definite lines determined by muscular and fascial barriers ; thus in the 
neck, abscesses are either prevertebral, bulging forwards into the pharynx, 
as in atlanto-axial disease, or point at the side in the posterior triangle, just 
behind the sterno-mastoid, sometimes on both sides. 

In the lower cervical and upper dorsal regions the abscesses, if they exist, 
rarely point externally, but if they do so either track down the spine and, 
appear as lumbar or psoas abscesses, or perforate an intercostal or intertrans- 
verse space and appear in the back. Abscess in upper dorsal caries com- 
paratively rarely points externally. Dorsal and lumbar caries commonly 
give rise to psoas abscess, the pus getting into the sheath of the muscle at 
its upper attachment and burrowing down within it, often entirely destroying 
the muscle itself; it then may either pass outwards into the iliac fossa, 
beneath the iliac fascia, and form a swelling there (iliac abscess), or, travelling 
on beneath Poupart's ligament, bulge in the thigh on the outer side of the 
femoral sheath as a psoas abscess. Often, however, though forming a col- 
lection in front, the matter does not point there, but, passing on behind the 
vessels towards the lesser trochanter, appears at the back of the thigh as a 
gluteal abscess. In other instances the pus finds its way round the edge of 
the quadratus lumborum and through the transversalis aponeurosis, perhaps 
in the course of a branch of a lumbar artery, and points in the back (lumbar 
abscess). Again, the pus may gravitate backwards into the pelvis and escape 
through the sciatic notch, appearing as another form of gluteal abscess. We 
have seen an abscess bulging at both sciatic foramina, so that fluctuation 
could be felt across the cavity of the pelvis. Less often the abscess descends 
over the iliac crest on its outer aspect, or burrows forwards between the 
layers of the abdominal wall. Once it has reached the thigh, matter may 
track down it for an indefinite distance. 

Deformity. — In most cases caries of the spine sooner or later gives rise 
to angular deformity (kyphosis). This is, of course, due to destruction of 
the bodies of one or more vertebrae, and consequent collapse of the column ; 
or possibly, to a certain extent, is caused by muscular contraction drawing 
together the adjacent bodies, the spines being thereby made to project 



Deformity in Spinal Caries 66y 

posteriorly. The amount of deformity in such cases varies from a mere faint 
prominence of one vertebral spine, only to be recognised by careful observa- 
tion, to a great prominent 'knuckle' involving six or eight vertebrae. When 
the disease is in the dorsal region, the falling together of the vertebral bodies 
produces a corresponding chest deformity ; the ribs are brought close 
together, the shoulders are raised, and the head looks sunken between them,, 
the antero-posterior diameter of the chest being increased at the expense of 
the vertical. 

In the cervical region the deformity is usually much less marked ; some- 
times, however, there is a prominent angular curvature, and the head is 
drooped forwards with the chin upon the sternum ; or the head and upper 
cervical vertebras are poked forwards with a projection backwards at the 
root of the neck. 

It must be remembered, however, that these deformities occur only in 
an advanced stage of destruction, and only when the whole breadth of a 
vertebra is eaten away ; thus, disease of one side or the posterior part of a 
body may exist without any angular deformity, and in some instances the 
spine is recurved, so that the convexity is forwards instead of backwards y 
this is most commonly seen in the cervical region : we have, however, seen 
it in the lumbar vertebrae too. In such cases the bending is never sharply 
angular, but is due to spasm of the posterior spinal muscles ; it can rarely, 
if ever, be due to destruction of bone, for to produce such result, not only 
the bodies but the arches of the vertebrae would have to be destroyed : the 
condition is generally merely an exaggeration of the normal curves. 

Since there is a physiological curve with its convexity forwards in the 
cervical and lumbar regions, a certain amount of destruction of the vertebral 
bodies has the effect of merely straightening these curves, and it is only 
when considerable erosion has taken place that a curve with its convexity 
backwards is produced. 

Extensive disease of the posterior parts of the bodies may, of course,, 
exist without any curvature, and in such cases the inflammatory material 
poured out may produce pressure on the cord or nerves, or inflammation 
by extension ; hence the old saying, ' The less the deformity, the more the 
paralysis.' 1 Paralysis in such cases is probably hardly ever due to bony 
pressure, since the spinal canal is not encroached upon ; this is only likely to 
occur where a sequestrum is pushed into the canal. 2 Lateral curvature 
sometimes results from destruction of the sides of the bodies and consequent 
collapse ; more often, however, any lateral curvature that does exist is a result 
of ligamentous and muscular weakness, and as such is a true lateral curvature. 

Before there is any permanent deformity from loss of material, certain 
characteristic attitudes are assumed by the subjects of spinal disease. In 
caries of the cervical spine the child often supports his head with his hands, 
to lighten the pressure upon the diseased spot and prevent any sudden jar, 
and is slow and careful in turning round and stooping. Where the dorsal or 
lumbar regions are involved, instead of bending the spine to reach any object 

1 It is also a matter of frequent observation that paraplegia and abscess are rarely 
associated. 

2 Paraplegia is commoner in cervical and upper dorsal caries than in disease lower 
down. 



■668 



Spinal- Disease 



upon the floor, the child bends the knees and hips, and so brings down the 
htands, and at every opportunity assumes the resting position shown in fig. 146. 
It is most important to distinguish angular curvature from lateral curva- 
ture and from rickety spine. It is only in the very early and very late 
.stages of disease that there is likely to be any doubt whether a case is one 
of lateral or angular curvature ; in ordinary well-marked cases the distinc- 
tion is clear enough. In some old cases of lateral curvature very sharp 

bends in the spine are much like 
angular deformity ; and again, we 
have more than once seen cases 
where there was an early lateral 
curve and no symptoms pointing to 
caries, yet in a few months un- 
doubted caries appeared. Careful 
and repeated observations are, there- 
fore, necessary if there is any possi- 
bility of doubt, and it must be re 
membered that the two affections 
may co-exist. Ordinarily a diagnosis 
is readily made by the presence in 
the one of a lateral curve and of 
rotation, and by the fact that the 
curve in caries is abrupt, in lateral 
curvature gradual, as well as by the 
presence or absence of the other 
symptoms of caries mentioned. 1 

The rickety spine is distinguished 
by its being a general rounded curve, 
by the absence of rigidity, by the 
disappearance of the curve when the 
child is held so that no weight comes 
upon the spine, by the evidences of 
rickets elsewhere, and the absence of 
the characteristics of caries. Caries 
also is very rare in the first two years 
of life, rickety spine much more common during that period. 

With these exceptions and the possible ones of an old fracture or dis- 
location, or congenital undue prominence of certain spines, or the develop- 
ment of bursse over the spines, the result of friction or pressure, angular defor- 
mity may be taken as pathognomonic of caries either present or pre-existing. 
Abscess is not by itself a certain indication, since it may be due to many 
other causes than spinal caries ; still, the presence of a lumbar, gluteal, iliac, 
psoas, post-pharyngeal, or cervical abscess should always lead to a careful 
examination of the spine. It must be remembered that pelvic disease, 
glandular, perityphlitic, perisigmoid, and perinephritic abscesses, empyema, 
carious ribs, sacro-iliac and hip disease, &c, may give rise to suppuration, 
which may point in positions identical with those in which spinal abscesses 
may find outlet. 

1 See also a paper by Lovett of New York, 1S90. 




Fig. 146. — Caries of the Spine, showing a cha- 
racteristic resting attitude, which should be 
contrasted with the rickety spine seen in fig. 74. 



Symptoms of Spinal Caries 66ty 

Rigidity is a most important sign of spinal disease, important all the 
more t>ecause it is an early one ; the stiffness is due to spasm of the spinal 
muscles, just as in disease of any other joint. Rigidity is best tested by 
stripping the child and putting some object upon the floor for him to pick 
up ; by watching carefully it will be seen whether the whole spine bends as 
in health, or whether it is held stiff- and immovable in any part. Healthy 
children freely bend their spines, but in order to fully test the mobility of the 
column the child should be told to keep its knees straight. Absence of 
flexibility is, taken alone, the most valuable sign of caries except deformity. 
In the cervical region, muscular spasm may give rise to wryneck, in- 
ability to nod or to turn the head round, according to the part involved. 

Besides contraction of the posterior spinal muscles, there may be rigidity 
of the ilio-psoas, causing flexion of, and inability to straighten, one or both- 
legs : this usually means that a psoas abscess is beginning to form, and the 
muscles are rigid in consequence of irritation, or kept voluntarily contracted 
to prevent pressure upon the abscess. Local rigidity of the lumbar muscles 
or of certain of the posterior spinal muscles will sometimes be found ; thus 
the erector spinas may be seen tightly contracted and standing out promi- 
nently just above the sacrum. 

The test of bending the body backwards is more applicable to adults 
than to children, in whom it is difficult to estimate amounts of pain ; it 
should, however, always be employed. 

Muscular wasting occurs in spinal as in other joint diseases, but is rarely 
well marked, except when the disease is far advanced, and hence is not of 
great value alone as a symptom. 

Dysphagia may result from pressure by an abscess upon the pharynx or 
oesophagus, or dyspnoea from pressure upon the trachea or lungs or upon the 
recurrent laryngeal nerves in disease lower down ; so too, possibly, extensive 
abscess in the chest may give rise to physical signs, dulness, &c. This is, 
however, more likely to be due to enlarged mediastinal glands. 

Large abdominal abscesses may produce pressure effects upon vessels 
and viscera, but these are rare results. Abdominal distension from flatu- 
lence may be due either to pressure upon nerves or to failure of the digestive 
powers in later stages, or to coincident tubercular disease of the intestines, 
mesenteric glands, &c. 

The subjective symptoms of spinal caries are pain and loss of sensation. 
Pain may be acute or nothing more than a feeling of tiredness or aching : it 
is usually an early and prominent symptom ; it may, however, be entirely 
absent, just as in some instances of chronic joint disease elsewhere. Usually 
there is pain over the affected spot, increased by pressure or jarring of the 
spine, such as may occur in jumping, or suddenly stepping down from a 
height ; in caries of the cervical spine, pressure upon the top of the head 
often causes suffering, and in any part of the column flexion or rotation 
movements may be painful. 

Further, there is usually pain in the course of the nerves passing out 
from the diseased area ; thus, in dorsal caries there is pain at the sternum 
or in the side; in dorso-lumbar disease there is abdominal pain ('girdle 
pain;' so called 'dry belly-ache '). Pains in the limbs, shooting down the 
legs over the distribution of the sacral and lumbar plexuses, and similarly in 



■6yo Spinal Disease 

the arms, may be met with. Any obscure pain should always be carefully 
traced to its source by searching along the whole course of the affected nerve 
up to its origin. Thus, pain in the back of the head, so-called 'headache,' 
may be due to pressure upon the occipital nerves, and so on. 1 

The anaesthesia and paresthesia due to spinal caries are either the result 
•of pressure upon the theca or nerves or of inflammation spreading from the 
bone to the meninges or cord, and will be found described in Chapter XXIII. 

Pain in the spine is sometimes increased by the application of warmth, 
e.g. a hot sponge applied over the diseased part, but the symptom is not 
constant nor of any great value. In some instances we have found herpes 
zoster occurring in connection with caries of the spine, and it is worth while 
to examine the spine in cases of shingles, since the eruption may be a result 
of lesions starting in the spinal column. 

The conditions most likely to be confounded with spinal disease are, in 
the neck, sprains or stiff neck from cold, reflex irritation, &c, glandular 
inflammation, and cervical cellulitis. The ' vertebra prominens' should be 
remembered, and the ease with which the cervical transverse processes can 
.be felt ; there is often a deceptive feeling of thickening about the cervical 
vertebras which is apt to mislead unless comparison is made with a healthy 
neck. In caries thickening will be felt. In glandular abscess the glands 
themselves can usually be felt to be enlarged, and generally the pain is 
most marked or only exists on one side, whereas in caries there is usually^ 
tenderness on pressure on both sides. This, with the other symptoms already 
mentioned, will serve to distinguish between the two conditions. Praever- 
tebral abscess, though often due to spinal disease, may be the result of 
several other lesions ; vide p. 73. 

Caries of the dorsal and lumbar spine has already had its distinguishing 
features pointed out ; it is only necessary to add that in all cases search 
should be made for evidence of abscess deep in the abdomen, since large 
collections of matter sometimes form very insidiously. 

Complications. — In addition to the troubles arising directly from the 
spinal lesions other complications may arise ; thus the vertebral disease may 
be only a part of a general tuberculosis in which viscera or bones and joints 
other than the spine may be involved. Sometimes a psoas abscess in track- 
ing down gives rise to disease of the sacro-iliac or hip joints {vide Hip 
Disease). As a result of pressure upon or inflammation of the spinal cord 
and its membranes cystitis or paralysis of the bladder may result ; bedsores 
may form both as a consequence of pressure and from the nerve lesions. 
Exhaustion, hectic, lardaceous disease, and general tuberculosis are the 
most common causes of death, though it must not be forgotten that sudden 
death may occur from displacement, the result of softened ligaments, in the 
upper cervical spine, or from bursting of an abscess into the air passages, or 
ulceration into a large vessel. In other instances pyaemia or some inter- 
current disease cuts life short. 

Paraplegia may occur in the course of spinal disease as a result of pres- 
sure from inflammatory exudation poured out into the spinal canal, from 
effusion pressing upon the nerve roots, an occurrence met with in the cervical 
1 For illustrations of these peripheral pains the reader is referred to Mr. Hilton's 
.admirable book, Rest and Pain, edited by Mr. Jacobson. 



Mode of Repair in Spinal Caries 6yi 

region ('cervical paraplegia' of Gull), from necrosis and projection of a 
sequestrum into the canal, or rarely from the angular bending of the spinal 
column. Paraplegia occurs most frequently in cases of caries of some part 
above the lower dorsal spine, more rarely in lumbar disease. The degree of 
paralysis varies from mere weakness with paresthesia to complete paralysis 
of the lower limbs, the bladder, the rectum ; or in rare cases the paraplegia 
may be complete below the lower cervical region. There are loss of power, 
diminished sensibility, exaggeration of the reflexes, more or less contraction 
of the limbs, and, in cases where the cervical or lumbar enlargement of the 
cord is involved, actual muscular degeneration. Pain may or may not be pre- 
sent. For details vide Chapter on Nervous Diseases ; Paraplegia, p. 534. 

Mode of Repair. — Repair in the spine takes place just as in other joints ; 
the carious or necrotic process ceases, and the tissue injured beyond recovery 
is either thrown off and comes away in the discharge, or is encysted and 
remains quiescent, giving rise to no more irritation. The granulation tissue 
either develops into fibrous tissue or ossifies, and the adjacent bone surfaces 
are wielded together ; in addition to this bony splints and buttresses are 
developed around the diseased spot and further strengthen it. 

It is possible in very early stages for the inflammation to subside, and 
the parts to return to their original healthy condition ; but once there is loss 
of substance the curvature is never lost, though the spine may appear 
straighter from development of compensatory curves, or from straightening 
out of other mere transitory yieldings due to muscular and ligamentous 
weakness. 

Treatment. — Disease of the spine requires treatment on exactly the same 
principles as disease of other joints, viz. rest and general hygienic measures, 
with such management of abscesses as each case may demand. 

The general treatment need not be specified here further than to say 
that nutritious and careful diet, iron, and cod-liver oil, together with good 
air— sea-air if possible — are the desiderata. The difficulties arise in 
obtaining rest and in the treatment of abscesses. Rest implies absolute 
fixation of the diseased part : this requires different arrangements in caries 
of the upper and lower parts of the spine. In cervical caries the best plan 01 
treatment is to put the child on a hard mattress, with a small pillow to fit 
in between the shoulders and occiput so as just to support the spine without 
straining it : a ring air or water cushion for the head answers very well. 
Sandbags not too tightly filled are then laid along each side of the neck, 
packed well in, and secured by one placed across above the top of the head ; 
a folded handkerchief should be carried across the forehead and fastened 
to the sandbags at the side to prevent any possible lifting of the head. 
Arrangements should be made for defalcation, &c, without disturbing the 
child, by providing a hole in the mattress or a separate part in the middle 
that can be slid out. We know no better plan than this, as advised by Mr. 
Hilton, where it can be carried out rigidly, but it is difficult to manage for a 
sufficient time. Extension by means of a head sling and weights may be 
applied in cases of cervical and high dorsal caries {vide Schapps, c Year Hook 
of Treatment,' 1895, P- 2 7°)- As soon as repair has fairly advanced, as 
evidenced by absence of pain for some weeks previously, loss of tenderness, 
and diminution of thickening, with drying up of any abscesses that may have 



672 Spinal Disease 

formed, the child should have on a stiff leather or poroplastic collar moulded 
carefully to the neck and occiput, and shaped to the shoulders below ; he 
may then begin gently and carefully to get about for a short time daily, but 
on the least sign of pain or swelling the original plan must be reverted to. 

Or a jurymast may be applied with a plaster or felt jacket, either in the 
original form devised by Sayre, or of a shape we prefer as less troublesome, 
and we think more efficient, as shown in fig. 147 : this- 
form has the advantage of providing elastic support, of 
not requiring to be made of steel, and of not tending 
to press upon the vertex. The jurymast must be 
carefully modelled to the particular case, and never 
removed, but the straps kept just taut. Failing the 
treatment in bed, the jurymast is, we think, as good a 
plan as any, though it is troublesome to manage. 
Various other methods, such as inflatable rubber collars, 
sawdust collars, &c, are used with advantage in suitable 
cases, i.e. when the disease is subsiding. Extension of 
the head by weights, the trunk being fixed, is some- 
times usefully employed, but requires care not to 
overstretch the softening ligaments. 

Caries in the upper and mid-dorsal regions requires 
as absolute recumbency as cervical disease, but it may 
be either in the prone or supine position, and sand- 
bags are not required ; the child should be fastened 
down by the simple plan shown in fig. 141 if he can- 
not be trusted to lie still. The jurymast plan is- 
applicable, of course, to these cases as well, and must 
be used in any case where the ordinary jacket cannot 
be so applied as to carry the weight of the upper part 
of the body. 

The ordinary plaster-of- Paris Sayre's jacket is in 
our opinion the best appliance for spinal caries in the 
lower dorsal and lumbar regions. In acute and rapidly 
progressing cases a period of recumbency should be 
insisted on, either with or without the jacket. Certain 
points are essential in the use of this appliance. 1. Any sharply projecting 
spines must be protected by padding round them, and by careful moulding 
of the plaster to avoid pressure. 2. The jacket must reach well up to the 
root of the neck in front and behind, being shaped out in the axillae;- this- 
may be done by carrying the bandages crosswise over the shoulders and 
cutting out the cervical part afterwards, or by careful adjustment of the turns 
without crossing the shoulders. 3. The lower border of the jacket must 
come down well over the crest of the ilium, so as to distribute the pressure 
and prevent the formation of sores on the crest and iliac spines. In fact, the 
jacket must be closely fitting and envelope the whole spine from neck to 
pelvis, and not be, as it too often is, a mere wisp round the waist. We 
generally apply these jackets in the out-patients' room, with the child lying 
on its face across two chairs with a gap between them ; the tripod may, of 
course, be used, but with the greatest caution, to prevent any stretching, and 




Fig. 147. — A Jurymast for 
Cervical or Upper Dorsal 
Caries. The altered shape 
of the upright makes it 
easier to fit, and it is not 
necessary to have it of 
steel ; it also prevents fall- 
ing forward of the head 
without making abso- 
lutely vertical traction. 
The spring of the steel is 
replaced by elastic cords 
in the straps, which have 
been omitted ' from the 
figure for the sake of 
clearness. 



Splints for Spinal Disease 



673 



it must be remembered that the point in applying a jacket is to fix the spine 
and prevent any further pressure, not to pull the surfaces apart— it would be 
as rational to put on powerful extension and counter-extension after excision 
of the knee, dragging- the bones away from one another, as to try to extend 




Up"; 



Q>T€l 



^ ^ 



3E 



CM 



m 



f f=}\ 



u 



ph 



Ph 




p^_^ 



I) E F 

Fig. 148.— Patterns of Splints for Spinal Caries, Laminectomy, &c. a, for fixing head, trunk, and 
lower limbs; b, for dorso-lumbar caries ; c, for upper dorsal : D, for dorsal disease : E, tor dorso- 
lumbar laminectomy; k, for fixing whole trunk and lower limbs in a case of lumbar or gluteal 
abscess, &c. These appliances are all Thomas's splints or modifications of them. 

a carious spine. Of the various modifications of the jacket we have no ex- 
perience, as we are quite satisfied with the results o( the 100 jackets a year 
we use. With careful management a jacket will last from nine months to a 
year if the child does not grow out o\~ it, but usually hospital patients require 

X X 



6/4 



Spinal Disease 



new ones every two or three months. The plan of putting on two jerseys 
and changing the inner one by tacking a new one to its lower edge, and then 
drawing it upwards beneath the jacket by pulling the old one over the head, 
is ingenious and saves frequent changing in some cases. Pain after a jacket is 

put on usually means pressure at some point, 
jjlj ^ and should lead to careful examination : if at 

"'■^g the hips or axilla?, it may be relieved by 

judicious packing or cutting out ; if in the 
back, the jacket must be removed, or it will 
cause sores. Free dusting between the jersey 
and the skin with powdered boracic acid, or, 
in dirty people, with pulv. hyd. ammon., is 
useful. From six to eight bandages are 
usually required for a jacket in a child ; they 
should be applied in spirals so as to cross and 
strengthen one another, and care must be 
taken not to allow the edges to be thin and 
weak. 'Dinner pads' are not necessary if 
the bandages are put on judiciously ; a soft 
patch in the jacket over the abdomen does 
not demand a re-application so long as the 
rest of the jacket is firm. In some cases, 
where, from the presence of abscesses in the 
back, or co-existent hip disease, or flexion of 
the legs from psoas abscess, a jacket is inap- 
plicable, we use a double Thomas's hip splint 
and find it very useful ; it ensures recum- 
bency, keeps the spine at rest, extends the 
legs, and does not interfere with dressings 
nor require removal (figs. 148, 149). Should 
the child be fit to be on its legs, it can get 
about, with crutches, in a double Thomas's 
splint. 

Poroplastic and other jackets have only 
doubtful advantages over the original Sayre's, 
and have many drawbacks ; they are rather 
applicable as protections after consolidation 
has taken place than as a mode of treatment 
for active disease. Of the various special 
apparatus we can only speak in the same 
terms, but not from actual experience of 
them ; we have never been tempted to try them. 

If it were possible to reach and remove the source of suppuration in all 
cases, the management of spinal abscess would be that of all other abscesses 
in connection with bone disease, but the question is not a simple one, and 
each case has to be judged for itself. In cervical disease, as a rule, all 
abscesses should be opened as soon as they develop, for they are apt to track 
widely down the neck or, pointing in the pharynx, to become septic or a source 
of danger from pressure. Hence antiseptic incision, by dissection at the pos- 




Fig. 149. — Caries of the Spine, with 
double ilio-lumbar abscess, treated 
by the application of a double 
Thomas's splint. 



Spinal Abscess 675 

terior border of the sterno-mastoid, is the best treatment. In one case where 
the disease was of the spinous process alone, we opened the abscess, and later 
removed the necrosed spine ; and this, perhaps, might sometimes be done in 
necrosis of the bodies as proposed by Mr. Treves more especially for lumbar 
necrosis. Opening the abscess in the pharynx is not a good plan, and should 
only be done in an emergency where the pressure is threatening suffoca- 
tion ; even then we should prefer to do tracheotomy and then open the 
abscess in the neck at leisure, allowing the tracheotomy wound to close. 

Abscess in the dorsal region is not very common ; if due to disease of a 
spinous, transverse, or articular process, the seat of disease may be reached ; 
if of a body, this is hardly practicable unless possibly after resection of a rib, 
and is probably not desirable. Abscess pointing in the lumbar, iliac, or psoas 
area is the condition most commonly met with ; as to its treatment, our 
opinion is that if the abscess is on the point of bursting, or gives rise to much 
pain, or is rapidly increasing, it should be opened at once with full antiseptic 
precautions — the opening being made in the loin if there is any cavity there 
of sufficient size, or, if not, in some cases it is a good plan to pass a long probe 
from the lower opening, iliac, psoas, or gluteal, as the case may be, and cut 
•down upon it in the loin. Where the abscess is chronic and stationary, and 
where no adequate treatment has been hitherto adopted, and there is not much 
pain, it is wiser, in our opinion, to wait. The pus may be absorbed, there 
may be no sequestra to keep up irritation, and the caries may subside with 
rest, while we cannot remove the disease if it does not subside. When once 
opened there is always the possibility of dressings slipping and the wound 
getting foul, with the usual result of slowly progressive or acute septic 
poisoning. As long as the child is not going downhill, it is usually, we think, 
wiser to leave well alone. All spinal abscesses, when opened, should be 
dealt with by the method already mentioned as suitable for chronic abscesses 
elsewhere, i.e. they should be opened freely, all their contents thoroughly 
scraped, wiped, and washed out ; the wall of the abscess being thoroughly 
cleaned, the cavity should then be injected with iodoform emulsion and the 
wound closed. Should there be subsequently evidence of sepsis from im- 
perfect management of the wound, it must be opened and drained, but this 
must be looked upon as a serious disaster. If, however, the wound heals with- 
out fever, but the abscess gradually refills, the failure is due merely to incom- 
plete removal of the diseased material, and the operation must be repeated as 
•often as fluid recollects. By this method excellent results will be obtained 
if, and this is the whole question, sepsis is avoided. As to lumbar explora- 
tion and removal of sequestra, the plan introduced by Mr. Treves, we 
confess we rather agree with Mr. Owen that, while opening the abscess 
as near the seat of disease as possible is of course good, it is but rarely 
that we can hope to make out the exact condition of parts or find the 
sequestra in situ, and the method is, as already pointed out, only appli- 
cable to lumbar disease. Nevertheless the abscess should be explored with 
the finger in order to ascertain the size, shape, and relations o\ die cavity, 
as well as to reach, if possible, the original seat of the disease, and remove 
any sequestra and scrape or sponge out any caseous lymph lying loose in 
the abscess cavity. This is, of course, quite a different matter from cutting 
down upon vertebral bodies. 



6/6 Spinal Disease 

Where paraplegia occurs strict recumbency in bed should be the treat- 
ment, with very careful general management and the utmost watchfulness to 
avoid bedsores. All discharges must be carefully cleaned away and the 
parts kept dry and powdered with boracic acid. Occasional washings with 
strong spirit tend to harden the skin and prevent pressure sores. Any con- 
tractures of the limbs should be prevented as far as possible by suitable 
appliances. The internal administration of large doses of iodide of potassium 
is highly recommended by our friend Dr. Gibney of New York, but it has 
failed in our own hands. Mercury may be tried with advantage in some cases. 
Counter-irritation in the form of blisters or the actual cautery is sometimes 
of service. Where the paraplegia resists all treatment for a long time, the 
question of trephining the spine ('laminectomy') and removing the source of 
pressure is to be considered. In one case in which we operated we removed 
a thick layer of lymph from within the spinal canal, and a paraplegia of six- 
months' standing, which had resisted all other modes of treatment, at once 
began to improve, but the benefit was only temporary. In two of our cases 
complete recovery of power of walking followed the operation, but we limit 
its application to cases in which paraplegia has persisted after at least six 
months' absolute recumbency. In cases where paraplegia has come on 
rapidly, and is due to pressure of an abscess, the operation should no doubt 
be done earlier (vide Thorburn, 'Brit. Med. Jour., : June 30, 1894). Dr.. 
Macewen has recorded some successful cases (vide Address, ' Brit. Med. 
Jour.,' Aug. 11, 1888). Within the last year or two a great impetus has been 
given to this operation, and sufficient success has been obtained to fully 
justify it in cases where paraplegia does not improve by long-continued rest. 
The cord may be compressed by sequestra or by an extradural abscess, or 
possibly by distortion of the spine, but most commonly the pressure is due 
to effusion of thick tough lymph on the surface of the theca. For details of 
the operation we must refer to the special works on operative surgery. After 
the operation some such apparatus as that figured (fig. 148, A, C, or e) should 
be applied until the parts have consolidated. Our own experience is that 
the operation is seldom called for, and that the great majority of cases of 
compression paraplegia improve by continuous rest in bed. 

Disease of the sacrum, with abscess pointing into the rectum, is a des- 
perate condition The abscess is certain to be septic, and can only be 
reached through the rectum until it has burrowed down to the sciatic notch, 
or unless it points at the back, as it may do. In one case we tried to remove 
the disease, but in consequence of an abnormal patency of the theca below 
its normal point it was wounded, and the child died of meningitis ; the post- 
mortem showed that any such operation would have been exceedingly diffi- 
cult, and probably impracticable. 

The prognosis in spinal disease depends upon the stage to which the 
mischief has advanced, the presence of other tubercular lesions, and the 
amount of care that can be bestowed upon the case. It is not necessarily 
bad, and under favourable circumstances is decidedly good ; but from one 
to three years' treatment or even more is required. 

Atlanto-axial disease is, as already remarked, rare in children ; it is essen- 
tially the same disease as tuberculosis of any other joint, but its importance 
depends upon the effects liable to follow softening of the ligaments and 



Costo-vertebral Disease 6jJ 

sudden displacement of the odontoid process, viz. sudden death from pressure 
upon the upper cervical cord. Occipital pain, rigidity and thickening of the 
neck, with perhaps paresis, are the general symptoms ; there may be special 
difficulty in rotating the head. The general rules for cervical caries apply 
in other respects to this locality. 

Disease of the costo-vertebral articulations sometimes occurs, either 
alone, or as a result of extension from disease of the spine or a rib. Pain, 
which may be radiating, and formation of abscess, are usually the only 
symptoms by which the disease can be recognised. The abscess may point 
either in the back or lumbar region ; possibly some cases of psoas abscess 
depend upon this lesion. It is likely to be mistaken for spinal caries, but 
the absence of curvature, the slight, if any, rigidity, and the unilateral pain 
and suppuration, as well as the results of exploration, will probably enable 
the difficulty to be cleared up. Fixation in a plaster jacket with, if neces- 
sary, a window for discharge, or, better still, one of the appliances figured 
(fig. 148), is the best treatment if the disease is intractable. 



6yS Club-foot, Deformities of Limbs, &c. 



CHAPTER XXX 

CLUB-FOOT, DEFORMITIES OF LIMBS, ETC. 

The deformity known as club-foot or talipes may be congenital or acquired. 
The varieties of the congenital affection are named as follows : — 

Talipes varus \ 

,, valgus [ ... 

„ equinus *e simple forms. 

„ calcaneus J 

Talipes equino-varus ) , . r 

i , ,- the compound forms. 

„ calcaneo -valgus j r 

Talipes cavus may be simple or associated/with equino-varus or equinus. 

The only common form of club-foot is equino-varus ; this deformity is 
sometimes called simply varus, but inasmuch as the distortion is a compound 
one in almost all cases, we shall consider it under the more accurate title — 
and this is the more necessary, since its successful treatment largely depends 
upon recognition of this complexity. Calcaneo-valgus is the next most 
common form ; the others are only occasionally met with, and as great 
rarities anomalous forms such as calcaneo-varus and equino-valgus are seen. 

The general appearance of congenital equino-varus is seen in the figures. 
The heel is drawn up (equinus) and the anterior half of the foot is adducted 
and rotated inwards upon an antero-posterior axis, the adduction and 
rotation taking place at the transverse tarsal joint. Considering this 
deformity more in detail, it will be found that abnormalities exist in the 
muscles, ligaments, bones, and fasciae of the foot, and, though the subject 
has long been under investigation, we owe to Mr. Parker and Mr. Shattock 
much of ourrecent information upon the share taken by these several structures 
in the maintenance of the malposition. We use the word 'maintenance 3 to 
show that we believe that the deformity is due to persistent fixation of the 
foot in a distorted attitude rather than to any active displacement caused by 
muscular or ligamentous contraction. In describing the anatomy of talipes 
we acknowledge freely our indebtedness to Mr. Parkers work. 1 

In talipes equino-varus the posterior ligament of the ankle joint, the 
anterior part of the internal lateral ligament, and the astragalo-scaphoid and 
inferior calcaneo-scaphoid' 2 ligaments are those which are especially tight. In 
addition to these the plantar ligaments and plantar fascia help to maintain 
the concavity of the sole of the foot which co-exists with the equino-varus. 

1 Congenital Club-foot, 1887. 

2 Constituting the ' astragalo-scaphoid capsule' of Parker. 



Talipes Equino- Varus 



679 



In severe cases the whole of the ligaments on the inner side of the foot are 
shortened, and there may be adventitious fibrous bands. 

Besides the ligamentous structures, the tibialis posticus and anticus, as 
well as the flexors of the toes, the short muscles of the sole, and the muscles 
of the calf acting upon the tendo Achillis, contribute to the maintenance of 
the deformity, though it has been shown that, with the exception of the 
tendo Achillis, all the rest may be divided, and yet, unless the ligaments are 
also cut, but little effect can be produced upon the malposition. This is, 
however, not always the case, and it is probable that the share taken by the 
different factors in talipes is not always the same. Mr. Parker places the 
resisting structures in equino-varus in early life in the following order of 
importance : — 

(1) The astragalo-scaphoid capsule. (2) The tendo Achillis. (3) The 
skin of the inner border of the foot. (4) The bony framework of the foot. 
(5) The other ligaments and muscles. 





Fig. 150. — Severe Talipes Equino-Varus. 



Fig. 151. — Very severe Talipes Equino- 
Varus. 



As to the bones the trochlear surface of the astragalus is increased poste- 
riorly and diminished in front, and the neck of the astragalus is lengthened 
and directed more obliquely inwards than normal ; the articular surface 
on the head lies further inwards than usual. The ' calcaneum lies in a 
position of exaggerated rotation inwards beneath the astragalus, and in 
one case was found fused with the navicular. 3 The lower ends of the tibia 
and fibula are rotated inwards. The exact form of the astragalus appears to 
vary with the severity of the case. 

The drawing up of the os calcis tends to throw the head of the astragalus 
downwards, and the front of the foot is inverted at the transverse tarsal 
joint, and so the scaphoid slips partially oft" the astragalus and comes 



68o Cluh-Foot, Deformities of Limbs, &c. 

articulate with the tibia. The cuboid, cuneiform, and metatarsals are also 
rotated inwards, and further retracted by the long and short muscles so as 
to contract the sole of the foot, thus producing cavus. In some cases all 
the tarsal bones show a tendency to curvature with the concavity inwards, 
and the direction of their articular surfaces is altered. The fibula may lie 
entirely behind the tibia, and the tendo Achillis, being brought close to the 
inner ankle, may lie nearer the posterior tibial artery than in the normal 
foot. In a case we dissected the flexor longus digitorum lay directly over 
the tibialis posticus. Bursas are found over the prominences of the foot, 
and may exist even in intra-uterine life. 

In early stages and slight cases it appears that the astragalus is natural 
in appearance, in more severe deformity it is wasted and the neck deviates : 
there is not, however, any constant relation between deviation of the neck 
and deformity. In one case that we have seen the rotation of the foot in- 
wards was, we thought, at the scapho-cuneiform, not at the transverse tarsal 
joint. The ordinary result of these changes is adduction and rotation 
inwards of the front half of the foot, with elevation of the heel figs. 150, 151). 

In valgus the whole foot is everted at the ankle or the subastragaloid 
joint, as well as rotated outwards at the transverse tarsal joint ; : and, further, 
the sole is flattened, or in infants oftener convex downwards, the tibialis 
posticus and calcaneo-scaphoid ligaments being stretched and the peronei 
shortened. 

In equinus the tendo Achillis and posterior ligament of the ankle joint 
are shortened and the astragalus is drawn back, so that only the front of the 
trochlea is between the malleoli : there are other less important displace- 
ments of other tendons.'- Talipes equinus is said to be an exceedingly 
rare condition as a congenital deformity ; we have seen a very pure example 
in which intra-uterine pressure marks upon the knees and shoulders were 
very obvious. in calcaneus the chief contracted structures are the ex- 
tensors of the great and lesser toes, the tibialis amicus, and the anterior 
ligament of the ankle joint ; thus the foot is flexed upon the leg and the patient 
walks upon the heel : the front of the foot may be much atrophied. The 
trochlear surface of the astragalus is prolonged forwards as far as the navicular 
facet, and the inner malleolar surface is prolonged forwards (Parker and 
Shattock). We have noticed extreme projection backwards of the os calcis 
in congenital calcaneus, as if the foot were partially dislocated backwards at 
the ankle, a deep depression existing over the front of the joint. Hollow 
club-foot (cavus) depends upon shortening of the muscles of the sole of the 
foot and the plantar ligaments, as well as the flexors of the toes, the tendo 
Achillis, and the tibialis posticus. By the arching of the foot and the drawing 
up of the heel the extensors of the toes are put upon the stretch, and hence 
the toes are drawn up in hyper-extension, so that the deformity known as 
' hollow claw-foot'" is usually produced. 

The compound forms of talipes need no special description, as they 
consist of combinations of the simple varieties. 3 

Etiology. — Many theories have been proposed to account for the occur- 

1 So that valgus is not the exact opposite of varus. 

2 Vide Mr. Parker's book. 

3 Holmes Coote, in St. Barth.'s Reports, vol. ii. 1866, describes a form of talipes 



Etiology of Club -Foot 68 1 

rence of club foot, and it is probable that most of them are true in certain 
cases ; we do not think any one cause alone will explain all cases of club- 
foot. 

Little considered talipes due to ' a morbidly excitable, retractile disposition' 
of muscles, comparable to the reflex torticollis of later life. 

Central and peripheral nerve lesions, causing spasm or paralysis of 
muscles, may account for some cases, where, for instance, spina bifida or 
absence of brain (anencephale) is associated with talipes ; on the other 
hand, Parker and Shattock found both cord and nerves perfect in a case 
they examined. In opposition to them, however, we must point out that the 
nutrition of the talipedic limbs is often impaired, and they are fat, flabby, 
and toneless ; 1 the muscles may, however, react normally to electricity. 
Intra-uterine pressure associated with deficient amniotic fluid (Cruveilhier; is 
no doubt the cause in some children. We have found talipes associated 
with intra-uterine constrictions and amputations from amniotic bands,- and 
in another case, alluded to above, the deformity co-existed with pressure 
marks ; but the distortion is also found where the liquor amnii is abundant, 
and such explanation hardly accounts for single talipes as the only mal- 
formation. 

A persistence of the natural early fcetal position (Eschricht) explains 
some cases (of equino-varus and, later, calcaneus) ; in others, again, deficient 
development of parts is the cause, as in cases where congenital absence of 
the fibula has produced valgus, and this may be compared with fig. 162, of 
absence of the radius producing club-hand. 3 Hueter supposed that obliquity 
of the neck of the astragalus was a cause, but, as shown by Parker, this may 
occur without talipes, and talipes may exist without it. Intra-uterine joint 
disease possibly explains some cases, and adhesions are found in certain 
instances in the joints. Cruveilhier, Forster, 4 Parker and Shattock. and 
Silcock have pointed out that where the limbs are interlocked in abnormal 
positions they will exert pressure on each side quite independently of the 
amount of fluid ; we have frequently seen cases where clearly the feet had 
interlocked : the one foot, being in a position of extreme calcaneo- valgus, was 
received into the concavity of the other, which had severe equino-varus/" 
For further discussion of the subject we must refer to the admirable works, 
so often quoted, of Messrs. Parker and Shattock, and, in acknowledging our 
indebtedness to them, we can confirm many of their observations by our 
own ; we think that nearly, but not quite, all of the cases can be explained 
mechanically by pressure or position in utcro, bad packing as it were, and 

consisting in rigidity of the tendo Achillis with subsequent development oi flat-foot, of 
which it appears to be an early stage ; he calls it ' rectangular talipes equinus,' the foot 
being kept at a right angle with the leg. 

1 Possibly this may be explained by the absence of natural exercise in utero, when the 
feet are interlocked or misplaced. 

- Parker and Shattock also mention a case of theirs. 

5 Club-hand is, however, probably the result of pressure causing arrest of development 
of the prse-axial border of the limb. 

1 Missbildungen des Menschen t Taf. \\\i. fig. i. , from Cruveilhier; the figure : .s copied 
in Bodenhamer, as the subject had also imperforate anus. 

■'■ Confirmation of this view of the causation of talipes is found in the other deformities 
similarly produced, such as ' genu recurvatum, -xc.' Vide figs. 164, 165, 



682 Club-Foot, Deformities of Limbs, &c. 

so-called 'club-hand' is, we believe, due to the same cause. One of thc- 
strongest proofs, to our mind, is the tendency seen in children to assume, long- 
after birth, the position they occupied in utero, with the feet or hands locked 
in the talipedal attitude. The result of habitual positions in producing curved 
bones in rickety children is interesting also in this relation {vide figs. 70, 
71, and 76, 77). 

It is sometimes said that talipes is merely an arrest of development, a 
' failure to unwind ' the foot from its earlier or later fcetal position : we 
think this hardly fully expresses the truth, there is something more ; an 
actual pressure and squeezing together of the parts in an abnormal position 
is certainly what has occurred — in most of the more severe cases at any rate. 

As to the degree of deformity, we cannot do better than quote Mr. 
Parker's words : ' When the cause begins to act very early in, and continues 
throughout, intra-uterine life, the deformity will be a very fundamental one ; 
whereas, if the cause begins to act at a later period, or if it be continued for 
a short time only, the resulting deformity will be less severe.' — 'Brit. Med. 
Jour.,' October 27, 18S8. 

The treatment of all cases of club-foot in children can be successfully 
carried out without any but the most simple apparatus, except in the rare 
instances where, from neglect, old cases may require tarsectomy ; we shall, 
therefore, confine ourselves to description of the methods we have found 
most useful, and omit all reference to costly and complicated appliances. 
The general principles of management are the same for the different forms 
of club-foot, so that we may take an ordinary case of equino-varus as a 
type. Several questions have to be considered, such as (1) When is treat- 
ment to be begun ? (2) Is a cutting operation to be performed ; if so, what 
structures should be divided, and at what age ? (3) When operation is 
required should all the tense structures be divided at the same time, and 
should reduction of the deformity follow immediately on the operation or be 
delayed ? (4) What is the best apparatus to apply ? (5) How long is treat- 
ment to be continued ? 

(1) It might be thought unnecessary to insist upon the treatment of club- 
foot being begun immediately after birth, but we have more than once had 
cases, several months or more old, brought for relief, in which not only had 
nothing been attempted, but the friends had been told the child was not old 
enough for any treatment yet. Of course with a child a few days old more 
can be done in a week than is possible in a month with an older child. Treat- 
ment should be begun without a day's delay. (2) The question of tenotomy 
has been allowed to become largely one of fashion, some surgeons advising 
it in nearly every case, and others insisting not only upon its needlessness, 
but upon the harm resulting from it. The rules we follow on this point are : — 
If the child is seen within the first few weeks of life, operation is very rarely, 
if ever, necessary. During the next two or three years two points have to be 
considered : first, what amount of care can be expended upon the case ; and 
secondly, how rigid -are the resisting structures, i.e. can the deformity be 
reduced by moderate force ? If the child can be thoroughly well looked after, 
and its splints applied regularly and intelligently, operation is not neces- 
sary in most cases under two years old, although it undoubtedly shortens 
the time required for reduction, and is sometimes desirable— certainly so 






Appliances for Club -Foot 683 

where there is much rigidity, and any doubt about the efficiency of the care 
and management. Where the .rigidity is so great in a child over three 
months old or thereabouts that the deformity cannot be completely reduced 
by reasonable force, operation should at once be performed ; such cases are, 
however, comparatively rare. We see no advantage in forcible ' redresse- 
ment' over a cutting operation. (3) In equino- varus there is, we think, little 
doubt that if all the resisting structures are to be divided, those which main- 
tain the varus part of the deformity as opposed to the equinus should 
certainly be cut at the same time, and before there is any attempt to remedy 
the equinus. The plantar fascia rarely requires division except in neglected 
cases. Authorities differ as to the risks of immediate reduction after teno- 
tomy. We do not think the matter is one of great importance, and generally 
settle the question by the interval that is to elapse before the next visit ; if 
more than two days, we usually correct the deformity at once. (4) As to the 
question of apparatus we may say at once that we have never used, or seen 
the advantage of, the more complicated instruments — shoes modified in 
various ways from Scarpa's, tali verts, and so on ; they are too expensive for 
the hospital class, and in all classes we are quite satisfied with the results to 
be obtained by much more simple means. 

Practically we find one of three appliances will meet almost every case : 
two are of Dr. Little's invention, and the third is a slight modification of 
Barwell's artificial muscle plan. To take a case of equino-varus in which 
the varus is to be remedied first. The first appliance is adapted only to 
infants or children a few months old. It is simply a strip of thick block- 
tin long enough to reach from the knee to just beyond the end of the toes 
when the foot is pointed (fig. 152). This is bent to fit the foot along its 
outer side in its full equino-varus position. It is then bandaged on, no 
attempt being made to remedy the equinus or varus ; when it is securely 
fixed to the leg and foot, the front of the foot (i.e. the part beyond the trans- 
verse tarsal joint), together with the tin, is gently bent outwards so as to 
slightly improve the varus, leaving the equinus unaltered. The foot is left 
in this position till the next day, or longer if absolutely necessary, when the 
bandage is reapplied and a little further correction employed, and so on till 
the varus is somewhat over-reduced. The equinus is then dealt with in the 
same way, the splint being applied to the back of the limb. The second 
appliance (fig. 154) is simply Dr. Little's tin splint. It maybe used with the 
foot-piece fixed at a right angle with the leg-piece, or better movable, so as 
to remedy the varus alone first. This splint is applicable to older and more 
rigid cases, as it is a much more powerful appliance than the last. It is 
useful sometimes to have a slit cut in the metal at the angle between the 
leg and foot pieces, running a little distance along the edge of the sole : 
through this slit the bandage is carried, and so the heel is more securely 
fixed clown. The third apparatus is Barwell's artificial muscle, applied 
somewhat simply. We use it in two different forms. The first form consists 
of Mr. Barwell's strip of tinned iron strapped to the front of the leg : on it is 
soldered a hook. A strip of strapping, or webbing, or felt is carried round the 
front of the foot, and to its free end is fixed a loop oi stout indiarubber cord 
or drainage tubing ; this is then stretched up to the hook above, so as to 
correct the deformity. The second way o\ applying the muscle is that 



684 



Club-Foot, Deformities of Limbs, &c. 



shown in fig. 153. The object of using the straps instead of the tin 
splint and plaster is to allow the apparatus to be taken off in order to rub 
and wash the leg, friction being a point to which we attach considerable 
importance, as tending to prevent, or at least remedy, the great muscular 
wasting which occurs in the course of the treatment of talipes if any rigid 
appliance is kept on constantly. The plan we adopt usually is to use one or 
other of the tin splints, generally the first, until the deformity is so far 
corrected that the muscle can be efficiently applied ; the latter is then worn 
till the cure is complete. 

As to the duration of treatment no hard-and-fast rule can be laid down ; 
it varies in each case with the rigidity of the parts, the age of the patient, 
and the care expended upon it. In one case a few weeks, in another many 
months, may be required before the artificial muscle stage is reached. As 




Fig. 152. — Little's Fig. 1^3. — The Artificial Muscle Appliance shown 
plain Tin Splint. correcting the deformity in a case of Congenital 

Equino-varus (from a photograph), a, the rubber 
strap or ' muscle ; ' b, strapping round the foot ; c, 
the side straps connecting the upper and lower 
straps. The apparatus is a modification of Bar- 
well's original plan. It is better to have the straps 
made to lace up than to buckle. 




Fig. 154. — Little's Tin 
Talipes Shoe, which 
may have a joint at 
the junction of the 
sole and leg pieces. 



soon as this can be profitably applied the drudgery of the task is over, but 
the case cannot be considered cured ; hence the answer to the fifth point, 
that of the duration of treatment, can only be general. As Dr. Little points 
out, no case is safe from relapse until the patient is old enough to watch him- 
self and correct the earliest sign of return of the deformity, although by the 
use of the artificial muscle another dictum of his, that there must be no 
walking till the deformity is remedied, may be set aside. Great care is 
required, in applying the splints, not to be deceived by the rotation of the 
limb, and until the artificial muscle can be applied so as to slightly over- 
correct the deformity no walking is to be allowed ; after this point is reached 
it does no harm, but rather good. The essence of the matter is largely in 
the amount of trouble taken with each case by the surgeon and the friends. 
Some other points in management must be also considered. Manipula- 
tion, i.e. firmly holding the foot in a slightly over-corrected position, is 



Treatment of Talipes 685 

exceedingly useful, and should be daily employed each time the splints are 
removed — or, if unfortunately, from pressure sores or other causes, the 
apparatus has to be left off, frequent manipulation prevents time from being 
lost. The leg should be firmly grasped in one hand, in such position that 
the patella looks directly forwards, and then the other hand should be used 
to steadily turn the foot into position, bearing in mind, in each case, the seat 
of the deformity ; thus in varus the ankle joint must be steadied and the 
rotation made at the transverse tarsal joint. 

Pressure sores are to be avoided by regular daily renewal of apparatus, 
and avoidance of rucking up of plaster or bandages ; though, perhaps, 
strapping is more apt to cause sores than webbing, 1 it is easier to keep on 
in the early stages of treatment ; we, however, generally use thin saddler's 
felt or webbing for the foot-strap, and carry it round the ankle and foot in 
the fashion shown in fig. 156, but reversed (B, fig. 153). 

Should it be decided that tenotomy is required in a given case, the rules 
for its performance are as follows. To divide the tibialis posticus the limb 
is laid upon its outer side upon a firm pillow, the posterior border of the 
tibia is felt for, and the tenotome passed in two fingers' breadths (in an infant) 
above the inner malleolus, in such position that its point just hits the edge 
of the bone ; the knife is then slipped close to the bone, between it and the 
tendon, and its edge turned towards the tendon ; the foot is then held so as 
to correct the deformity, and by a gentle levering motion the tendon is 
divided, cutting towards the skin ; as soon as the tendon is felt to snap the 
knife is withdrawn and a collodion pad and bandage applied. Occasion- 
ally bleeding is free, but readily stops on pressure, and no bad result 
follows. If the edge of the tibia cannot be felt, a point midway between the 
front and back of the limb marks its position. The better plan is to divide 
the tibialis posticus, together with the ligaments, through one puncture 
opposite the transverse tarsal joint in the posterior crease of the sole. 

The tibialis anticus is best divided upon the dorsum of the foot, just before 
its insertion into the inner cuneiform ; it is easily felt, and the knife passed 
beneath it, and division effected as in the posterior tendon. 

The tendo Achillis is perhaps the simplest of all. It should be cut 
about f inch above its insertion, at its narrowest part, the knife being passed 
well beneath it (i.e. nearer the tibia), from the inner side while the limb lies 
on its anterior surface. Personally we prefer to pass in the knife while the 
tendons are held tense and can be plainly felt ; others prefer to tighten only 
after the tenotome is beneath the muscle. 

We are much in favour, in suitable cases, of Mr. Parker's plan of dividing 
all rigid structures at the transverse tarsal joint, and not limiting the section 
to the tendons or fascia. The tubercle of the scaphoid should be felt for 
and the knife passed in at the inner border of the foot, just behind the bone ; 
the edge is then turned towards the joint and made to cut well into it, 
dividing everything until the foot readily yields ; by thus severing the 
ligaments subsequent reduction is rendered much easier. Where this plan 
is adopted, the tibialis posticus and anticus are divided at the same time as the 
rest of the rigid structures ; the internal plantar artery is necessarily cut, and we 
have once seen a traumatic aneurism result, but no serious ill-effect need be 
1 Vide Golding Bird, Guy's Hospit ,1882. 



686 Club-Foot, Deformities of Limbs, &c. 

feared, even if bleeding is free at the time. 1 The anterior and posterior 
ligaments of the ankle joint require division in some cases of calcaneus 
and equinus respectively. 

It should be remembered that in second tenotomies the characteristic 
snap is often not felt. 

We are not satisfied with the results of fixing feet in plaster of Paris, 
either with or without tenotomy, but much prefer an arrangement where the 
pressure may be altered frequently. 

Where the artificial muscle plan is being employed, if tenotomy is re- 
quired at all, it is usually the tendo Achillis that needs division, since the 
plaster is apt to slip up towards the heel in such cases. Where the other 
splints are used, it is better, since the varus is corrected first, to divide the 
tibial tendons, &c, three or four weeks before the tendo Achillis ; some 
surgeons prefer always to divide the Achilles tendon first. The peronei rarely 
require division (we have never seen a case suitable for peroneal tenotomy) ; 
if they do, the section is made two fingers' breadths above the outer malleolus. 
The extensor longus digitorum and proprius hallucis may be divided just below 
the annular ligament, but we have never found the operation necessary. 

Congenital valgus is best treated by a muscle applied so as to exert 
pressure in the opposite way to varus ; it is, however, not so readily corrected. 
The rare equinus requires muscles on both sides to draw up the toes, usually 
after tenotomy. Calcaneus is best treated by the tin strip (fig. 1 52) or jointed 
splint (fig. 154). 

Talipes cavus is often remedied by division of the tendo Achillis only ; 
in other instances the resisting structures in the sole may require section. 
Where there is much cavus with equinus it is sometimes necessary to attach 
the ' muscle ' to a thin metal plate moulded to the balls of the toes, to prevent 
the foot-strap from slipping into the hollow of the sole. 

There is no doubt that tenotomy alone is in many cases inadequate, and 
will, with the exception of division of the tendo Achillis, be largely given up 
in favour of the more complete and scientific operation of ' syndesmotomy ' 
(division of ligaments) described by Parker. Of ' open division ' of all the 
resisting structures, including the skin, we have little experience ; we have, 
however, had one or two cases in which after ' syndesmotomy ' at the trans- 
verse tarsal joint the skin has given way under the strain of forcible reduction 
of the deformity. The only harm resulting has been delay in the healing of 
the wound and some little increase in difficulty in the application of the 
' muscle,' The principle of the plan does not commend itself to us. 

Excision of one or more bones of the tarsus for inveterate club-foot, as 
employed by Davies Colley, Davy, Lund, and others, is an operation to be 
reserved for severe cases in older children, and only employed when there is 
no hope of remedying the deformity by other means. 

The operation we prefer consists in making a J_-shaped or oval incision on the outer side 
of the foot, the horizontal limb running along the outer border, and the vertical part passing 
across the centre of the cuboid. The flaps are reflected, the bones exposed, the tendons 
being drawn aside, and a wedge of bone is removed entire or piecemeal from the outer 



1 Other cases of aneurism following division of the plantar fascia are on record — vide 
Walsham, Lancet, January 28, i883. 






Acquired Talipes 687 

side of the foot ; a chisel is the most convenient instrument for the purpose. Various lines 
of section are employed, but the general rule is to remove the cuboid always, and as much 
of the adjacent bones as the individual case may require; the cuneiforms, head of the 
astragalus, bases of the metatarsal bones, and front of the os calcis may all require to be 
taken away. 1 After the operation the foot should come readily into position ; all bleeding 
having been stopped, and the dressings applied, the limb is at first fixed lightly on a back 
splint. The wound often heals somewhat slowly, and until it is superficial we prefer not 
to use forcible corrective apparatus ; usually in about a fortnight a muscle may be applied. 
It is a good plan to take away an oval piece of the thick callous skin and the under- 
lying bursa from the dorsum of the foot. We look upon the operation as a very valuable 
one in suitable cases — for instance, where the patient walks upon the dorsum of the foot 
and pressure sores are prone to develop, while all the structures are rigid {vide fig. 151). 

Excision of the astragalus alone, we think, is best adapted for paralytic cases — in such 
instances we have removed the bone with excellent results ; it may be done without division 
of any important structure, by an incision over the ankle joint, carried from the tibialis 
posticus to the tibialis anticus, and another one at right angles to this, along the inner 
border of the latter tendon. By a little careful dissection the bone can be got out, the 
only difficulty being with the interosseous ligament. After the operation a shapely foot 
with a good arch still remains. 

The most common forms of paralytic (acquired) Talipes are equino- 
varus and valgus ; these, so far as the deformity goes, are usually readily 
treated by the artificial muscle method, and the effect is generally immediate 
and to a certain extent satisfactory ; it does not, of course, remove the weak- 
ness and flabbiness of the foot, but it prevents actual turning outwards or in- 
wards, and makes walking much steadier and more sightly. In some few cases 
light steel supports are of value. Where, however, from long neglect the 
deformity is irremediable by these means, the method of excising the astragalus 
already described may be required. In very severe cases of infantile paralysis, 
where the foot is perfectly powerless, and especially where the paralysis ex- 
tends above the knee, and the knee joint is flexed, the limb being flail-like, 
short, and useless, amputation may be required ; this, however, should never 
be done in childhood, since there is a possibility of improvement. The 
attempt to convert the flail-like distorted limb into a stiff stable support by 
resection of the knee and ankle joints ('arthrodesis') has been tried, with satis- 
factory results, in some cases ; in a case we operated on in 1884, there was 
very considerable improvement — this was, we believe, the first case operated 
upon in this country. Walsham 2 has practised shortening the tendons by 
excision of a part and suture of the divided ends, thus correcting the de- 
formity and allowing the lax muscles to act ; we have also tried the plan, 
with fair results in two or three cases. It is sometimes of much value. 

1 The principal modes of tarsectomy are : — 

1. Excision of a wedge of bone, irrespective of joint lines (Davies Colley). 

2. ,, ,, cuboid (Little). 

3- .. .. astragalus (Lund) (chiefly, we think, applicable to acquired talipes). 

4. ,, ,, astragalus, cuboid and scaphoid (West). 

5. ,, ,, wedge from the neck of the astragalus (Hueter). 

6. Linear osteotomy of the tarsus or of the leg above the ankle joint (Hahn). 

7. Excision of a wedge- from the transverse tarsal joint, &c. (Rydygier) : : ide Rydy- 
gier, Berlin. Klin. Woch. February 5, 1883; also Lorenz, Wiener Klinik, 1884, H. 5 
and 6 ; also Goldschmidt, Rev. Mens, des Maladies de VEnfance, from c 

No. 17, April 1884. 

- Brit. Med. Jour. June 1884. 



6SS 



Club- Foot, Deformities of Limbs, &c. 



These paralytic limbs are, of course, prone to become the seat of chil- 
blains and ulcers from defective nutrition. 

Apart from the cases above mentioned of paralytic talipes, where the 
structures are loose and flabby, are the deformities in which contractures 
have taken place as a result of paralysis of certain groups of muscles. Of 
these the most common are talipes cavus (arcuatus or plantaris), in which 
after paralysis of the extensors of the foot the muscles and ligaments of the 
sole and calf contract, producing varying degrees of deformity and con- 
cavity of the sole of the foot, together with elevation of the heel (equinus). 
In some instances the pointing of the foot produces secondary retraction of 

the toes (hollow claw- 
foot) by the strain of the 
extensors of the toes. 
The distortion resulting 
from the conflicting forces 
occurs mainly at the ankle 
joint, the medio-tarsal and 
the metatarso-phalangeal 
joints. All grades of de- 
formity are met with, from 
slight exaggeration of the 
arch of the foot to the 
most extreme equinus. 
Much more rarely the 
converse deformities are 
met with. 

In slight cases, mani- 
pulation or the use of 
artificial muscles without 
any operation will remed) 
the distortion, but in the 
severer forms of old- 
standing cavus and 
equinus, division of the 
tendo Achillis, or of more 
or fewer of the resist- 
ing structures in the sole, 
will be required. After operation an artificial muscle should be used, and 
kept on till all tendency to recontract has ceased. In troublesome cases 
of ' cavus ' we attach the artificial muscle to a thin steel sole plate, which 
is modelled to fit over the balls of the toes, and so get over the difficulty of 
the tendency of the foot-strap to slip into the hollow of the foot. Some 
good figures of these cases are given in a paper by Mr. F. R. Fisher, 
'Lancet,' January 19, 1889. 

Patients, the subjects of club-foot, often suffer from complications of this 
condition. Bursas develop ovei the points upon which pressure is made, and 
these may become inflamed and suppurate, giving rise to obstinate sores, 
which will not heal and acquire callous edges. In some cases rest and 
ordinary treatment suffice, in others tarsectomy or even amputation may be 




Fi.£ 



[55. — Acquired Talipes following measles, probably due 
to infantile paralysis. 



Flat- Foot 689 

called for. Pirogoff's or even Chopart's operation should usually be done 
in such cases in preference to Syme's amputation. 

The whole foot and leg in severe cases is smaller and weaker than the 
other, and often shorter. The wasting of muscles, &c, is extreme in some 
instances, even when no paralytic condition has existed. 

The movements of the ankle joint become altered, and it develops into 
a ball-and-socket rather than a ginglymoid joint (Jorg). The metatarsal 
bones are usually shorter than normal, a condition due to the contraction of 
the plantar fascia, according to Borck. 

Treatment of club-foot in all cases must be kept up constantly until all 
tendency to relapse ceases. Dr. Little remarks that such patients require 
watching until puberty, and, as already pointed out, the result depends 
entirely upon the amount of care and perseverance expended upon them. 

Relapsed club-foot after tenotomy is much more difficult to treat than it 
is in cases where nothing has been done ; tenotomy should, however, be 
repeated and the usual methods carried out. 

Flat-foot. — Apart from congenital and paralytic valgus is the common 
condition known as spurious valgus, pes pronatus acquisitus, pes planus, or 
commonly flat-foot. Though this affection is not by any means peculiar to 
childhood, it most commonly comes on in the later years of childhood or 
adolescence ; sometimes, however, it occurs earlier. 

The condition is essentially one of relaxed ligaments and muscles, and 
comes on usually in weakly, overgrown children, who have been kept too 
much on their feet — especially if they are rickety also. It is one of the 
conditions arising in so-called ' rickets of adolescence.' 

The prominent part assigned to relaxation of the inferior calcaneo- 
scaphoid ligament in the production of flat-foot is hardly deserved, since the 
tibial muscles, the flexors of the toes and pollex, the short sole muscles, the 
plantar ligaments, the plantar fascia, and the peroneus longus all take a 
share in supporting the arch, and the condition is in most cases the local 
expression of a widely spread weakness rather than the result of yielding of 
any one structure. In a few cases flat-foot is the result of injury. 

Lowering and inward projection of the head of the astragalus, with loss of 
the arch of the foot and its elongation, are the prominent features of the 
affection. The sole may be flat or even convex, and the inner border early 
becomes convex also ; there is usually pain over the head of the astragalus, 
often also across the dorsum of the foot and beneath the outer malleolus, and 
very commonly also in the first metatarso-phalangeal joint (so-called k meta- 
tarsalgia'). Often the patient applies for relief entirely because of the pain 
in this joint. 

The prominent projecting mass on the inner aspect of the foot is not. 
however, by any means always the head of the astragalus only ; it is often 
the tubercle of the scaphoid, since this bone is frequently pressed downward 
and inwards by the astragalus, so that yielding takes place rather at the 
scapho cuneiform than at the astragalo-scaphoid joint. In some cases the 
prominence is shared equally by the astragalus and scaphoid. In any ease 
where the deformity is marked there is a deep depression on the dorsum of 
the foot, due to the slipping away o( the head o( the astragalus. 

In early stages the deformity is only seen when the patient is standing, 

\ \ 



mm 



690 



Club-Foot, Deformities of Limbs, &c. 



when the whole foot may be seen to collapse and spread out in a toneless 
fashion, the transverse arch also giving way. In later stages the foot becomes 
fixed in its distorted position, and cannot be replaced. In intermediate 
stages replacement is possible ; sometimes in manipulating the foot adhe- 
sions give way and the arch is restored for the time. These adhesions are 
the result of chronic inflammatory changes which are specially prone to 

occur in the metatarso-phalangeal joint of 
the great toe, but may attack several joints 
and the sheaths of the tendons. 

The treatment of this disease consists in 
preventing the child from standing long at a 
time, and improving its general condition ; 
next, the deformity must be reduced ; in 
ordinary cases an artificial muscle, applied 
so as to support the head of the astragalus, 
is perfectly efficient in relieving pain and 
restoring the arch of the foot, and any 
reasonable amount of standing and walking 
can be done from the first as soon as 
this is applied. It is the only form of 
apparatus we use now, and it very 
seldom fails if properly applied. In some 
cases it may be necessary to break down 
adhesions first, but in children this is rare. 1 
It is, however, important that the foot be 
moulded into good shape each night and 
morning. (Fig. 156.) 

Standing and walking on tiptoe, dancing, 
and friction are all useful supplementary 
means, as pointed out by Ellis,- who is of 
opinion that the flexor longus pollicis is a 
very important factor in tying together the 
pillars of the arch of the foot (' Lancet,' 
February 9, 1884). 

No operation is ever required for acquired 
flat-foot in children. 
u/*% ■ -'^ji^^S^'- A form of distortion in which there is ad- 

duction of the foot, or rather rotation inwards, 
in which the deformity depends upon a rota- 
tion of the whole leg, is sometimes met with. 
It gives rise to the condition popularly known 
as ' duck toes.' The unsightly gait may be 
due to congenital malposition or to rickets ; it has been proposed to call 
the deformity ' club-leg,' and to remedy it by osteotomy of the femur {vide 




Fig. 156. — Shows an 'Artificial Muscle' 
applied for Flat-foot. 



1 The best paper on the subject with which we are acquainted is that by Air. Golding 
Bird already alluded to [Guy s Reports, 1882). From it we have learnt much. 

2 Some surgeons believe that weakness of the peroneus longus is the essential factor in 
flat-foot, and recommend faradisation and galvanism. 



Wry -Neck 



691 



.supra, chapter on Rickety Deformities ; also Parker, ' British Medical 
Journal,' Oct. 27, 1888). 

Wry-neck or Torticollis is a fairly common affection in childhood, 
and may be due to any of the following conditions : — 

1. It may be congenital, probably due to malposition in utero — sometimes 
to mal-development, as in a case of our own, in which wry-neck, deficient 
development of the external ear, mastoid region, and lower jaw co-existed with 
cleft palate and mental deficiency. 1 

2. It may result from injuries at birth, lacerations of muscles, &c. Volk- 
mann has found the sterno-mastoid represented by a band of cicatricial 
tissue. Sterno-mastoid tumour (p. 23) is sometimes followed by torticollis, 
the injured muscle subsequently becoming contracted. We have had at least 
four cases in which there was a history 

of sterno-mastoid tumour in infancy. 
See D'Arcy Power, ' Med. Chir. 
Trans.' vol. lxxvi., 1894. Petersen, 
"however, thinks the haematoma is a 
result of injury to the previously short- 
ened muscle. 

3. It may be spasmodic, due to 
central or peripheral nerve lesions or 
reflex irritation. 

4. It may result from suppuration 
in the neck, clue to either glandular 
abscesses or cervical caries, causing 
matting together of the parts and con- 
tracture of the muscles. 

5. Burns or other injuries may, of 
course, produce cicatricial torticollis. 

In its most simple form wry-neck 
is due to contraction limited to one 
sterno-mastoid, which is felt as a hard 
tight cord in the neck ; the head in 
such cases is drawn down towards the 
shoulder, and the face turned towards 
the opposite side (fig. 157). 

Golding Bird- is inclined to con- 
sider the condition due to a cerebral lesion analogous to the cord lesions in 
infantile paralysis. 

In other instances the sterno-mastoid is not alone affected, but the sea- 
leries, trapezius, and cervical fascia contribute to the deformity. 

Treatment. In slight cases in quite young children regular daily stretch- 
ing and manipulation of the rigid muscles may suffice to get rid of the de- 
formity. In the severer forms of the affection tenotomy is the only effectual 
treatment. The sterno-mastoid, and sometimes the trapezius, require divi- 
sion. For tenotomy of the sterno-mastoid the knife is passed through the 

1 Intercalations of more or less developed vertebral bodies may produce wry-neck of 
one kind, as it maj lateral curvature. 

8 Guys Reports, 1890 ; vide also Murray, L 

\ \ a 




KB 

: 57- ~ Congenital Wry-neck. 



692 



Club- Foot, Deformities of Limbs, &c. 



interval between the two heads, and its edge turned forward against each in 
succession, the child's head being held stretched by an assistant. Care 
must, of course, be taken not to Avound the anterior jugular vein at the front 
edge of the muscle, or the external jugular at the posterior border, nor to 
carry the knife so deeply as to endanger the carotid sheath. We usually 
divide the muscle through a puncture at the anterior border ; if preferred, a 
blunt-pointed tenotome may be used. Where the cervical fascia is also tightly 
contracted it may be necessary to divide it, but this step is by no means free 
from danger, and in such cases it is safer to make an incision over the 
muscle and gradually dissect through the rigid parts in an open wound. 

Some surgeons prefer to divide 
the muscle at its middle. Two 
days after the tenotomy the ap- 
paratus (fig. 1 58) recommended 
by Mr. Southam should be applied. 
The following case is character- 
istic : — 

Case. — Torticollis. — John Wm. G. , 
age 5 years ; admitted August 5, 1885. 
A neurotic family history ; the child 
has never been strong ; the deformity 
is congenital, but has been getting 
worse lately, and is increased when the 
child is not well ; has lately had tooth- 
ache on the left side. On admission 
the left sterno-mastoid is contracted in 
its whole extent, forming a firm, promi- 
nent band ; the interval between the 
tendons is deeply marked, the sternal 
tendon being the most prominent. The 
chin is rotated x\ inch from the middle 
line downwards and to the right ; the 
platysma is also prominent. August 13, 
tenotomy of both heads through the in- 
terval ; the cervical fascia was also par- 
tially divided. Antiseptic operation and 
wood-wool dressing. 14th, no pain ; 
the head was packed in sandbags. 17th, 
a plaster-of-Paris jacket was put on 
with hooks fixed in it, and a rubber muscle was applied parallel to the right sterno-mastoid, 
attached to the head by circular bands of strapping. 20th, another muscle was applied 
in a corresponding position at the back. 22nd, made out-patient. He was seen subse- 
quently, and hardly any visible deformity remained. November 10, 1885, quite well. 




Fig. 158.— Artificial Muscle applied for Wry-neck 
after division of the Sterno-mastoid. A Sayre's 
jacket is applied to the trunk, and iraction made 
from a poroplastic cap or ring of strapping. 



Spasmodic torticollis, if it does not yield to medical treatment, may re- 
quire stretching or resection of the spinal accessory nerve— all causes of 
reflex irritation, carious teeth, worms, otorrhcea, enlarged glands, &c, having 
been previously removed. 

The other forms of wry-neck require treatment on general principles, or 
are irremediable ; special care must, of course, be taken not to overlook the 
presence of cervical caries. 

In all cases of wry-neck, where manipulation is admissible, steady and 



Congenital Deficiencies of Muscles — Tenosynovitis 693 

regular attempts should be made to remedy the distortion ; friction and 
steady stretching of the neck with the hands should be tried, and the child 
made to practise, before a looking-glass, trying to hold the head straight. 
To supplement these means, various apparatus, collars, &c, may be used ; the 
one we have found most efficient is that figured for use after tenotomy. In 
quite young children, of course, no voluntary help from the child can be ob- 
tained, but the friends must be instructed what to do, and in older patients 
it is a good plan, as Mr. Roth has pointed out, to get the child familiar with 
the exercises before the tenotomy is performed, so that no time may be 
wasted afterwards. 

Congenital cases, where the sterno-mastoid alone is involved, are usually 
completely curable ; many of the spasmodic cases get well either sponta- 
neously or after removal of some source of irritation. In cases where the 
scaleni are involved there is more difficulty. So far as we know, these 
muscles have not been divided for such condition, but there seems no reason 
why they should not be, provided a suitable case occur. In many of these 
patients the face is undeveloped or distorted on the affected side ; secondary 
lateral curvature of the spine may also result. 

It is certain that the condition already described as sterno-mastoid 
tumour sometimes leads to subsequent development of torticollis from cica- 
tricial contraction of the muscle, and Owen has actually watched such a 
case ; in the many cases we have seen, such result has followed in at least 
four instances, and D'Arcy Power has collected a number of other cases. 
Op. cit. 

No treatment is required for the sterno-mastoid tumour except that watch 
should be kept for the slightest sign of onset of the torticollis, and suitable 
preventive exercises employed {vide also pp. 22, 23). 

Congenital Deficiencies and Malformations of Muscles are often 
slight, and interesting from an anatomical rather than a surgical point of 
view ; in other instances, such as those where the pectoral muscles are absent, 
in association with arrest of development of the chest- wall, the malformations 
are irremediable ; in others, again, some help may be obtained by elastic cords 
(' artificial muscles '), or possibly by the transplantation of muscle flaps ; for 
the most part, however, these conditions are beyond the present reach of 
surgery. 

We must just mention the very rare condition known as myositis ossificans, 
of which a remarkable instance was lately under our care. The patient was a 
child of six years old ; the affection began about a year before and was steadily 
progressing ; cervical, pectoral, brachial, abdominal, intercostal, and femoral 
muscles were many of them more or less affected, without any disturbance of 
health so far. No cause is known for the disease, and no treatment seems 
to be of any avail ; the subjects of it usually die from interference with the 
respiratory movements or some intercurrent illness, though they may live 
for years. 

Tenosynovitis is an affection common in, but by no means peculiar to, 
-childhood. Tubercular tenosynovitis is, however, not rare, usually as a 
secondary condition to joint disease, but occasionally occurring alone ; its 
existence is to be suspected when swelling and suppuration occur in the 
course of a tendon in a tuberculous subject, and its treatment must lie on 



694 Club -Foot, Deformities of Limbs, &e. 

general principles — rest and constitutional measures in early stages, and 
careful scraping out in the severer ones. We have once or twice seen sup- 
puration in the large palmar sheath, and in one instance it occurred in a pre- 
mature child only a few weeks old. coming on without assignable cause : 
secondary pyaemic abscesses elsewhere followed, but the child ultimately got 
quite well. 

Bursee in children are not usually very well developed. Patellar bursitis 
is. however, not very rare, and we have seen it lead to disease of the knee- 
joint ; the olecranon bursa is also occasionally enlarged, while effusion into 
the semi-membranosus bursa is not uncommon. Ganglion is most common 
in the radial extensor tendons and in those of the thumb : in recent cases the 
fluid may be dispersed by pressure, in others it should be punctured with a 
grooved needle and the clear gelatinous contents let out : a pad with firm 
pressure should be kept on for three weeks afterwards, or the sac is likely to 
refill. In obstinate cases the sac should be laid open and as much of it as 
possible dissected away. 

Malformations. — Other congenital malformations may be conveniently 
considered as i those due :o errors of growth in the embryo itself — in- 
herent errors l — and 2 those due to abnormal intra-uterine surroundings — 
acquired errors : or they may be classified as deformities by excess, deformi- 
ties by deficiency, and deformities by distortion. In either case it is some- 
what difficult to assign to their proper place all the malformations met with, 
and fortunately it is of little practical importance, as far as treatment goes. 
that we should do so. 

Among inherent errors may be classed supernumerary fingers and toes — 
polydactylism : some cases of web fingers and toes — syndactylism : tri- 
podism : congenital tumours of the dermoid class — with which might be put 
the cases of so-called fcetal inclusion. Possibly certain less-marked malfor- 
mations, such as those affecting only some of the structures of a limb, con- 
genital varices, venous and lymphatic, congenital muscular abnormal::: es, 
Sec., should be placed here, though these, in so far as they are of surgical 
importance, are more conveniently considered under the organs to which 
they belong.- Many instances of inherent errors are better seen in the head 
and trunk, such as failure of closure of the dorsal and ventral laminae and 
of the visceral arches of the head, meningocele, spina bifida, harelip, extro- 
version of the bladder. &c. 

Among acquired errors are all those due to intra-uterine pressure, either 
by the walls of the uterus itself, by amniotic bands Gurlt ,'-' by pressure or 
violence applied to the uterus from without, or by mere malposition of the 
foetus in utero, at whatever period of gestation they arise 

In considering what malformations should be placed in this group, we 
must remember that it is probable that pressure or violence acting in a very 
early stage of development leaves much less obvious signs of injury than if it 
is inflicted at a later period : thus constriction or pressure curing the later 

1 ' Vices of conformation.' 

- Or, as Montgomery has pointed out, by bands of lymph stretching from one part 
of the fcetus to another ; cf. Intra-uterine Amputation, p. 696, and vide Todd's Encyclo- 
pedia. 



Intra-uterine Amputation 695 

months of pregnancy may leave distinct cicatrices, while the same forces 
applied earlier may cause deficiencies without any marks of violence or scars. 1 

In this group will be placed deficiency of limbs, fingers, &c. fintra-uterine 
amputation), as examples of the highest degree of deformity ; also congenital 
constrictions and dimples, together with congenital synostoses or deficiencies 
of parts or the whole of a limb, such as absence of one or more of the carpal 
or tarsal bones,- of the lower end of the radius or ulna, causing club-hand ; or 
mere faults of position such as are found in club-foot, flexed or hyper-extended 
joints, &c. 

The proof that some of these deformities are the result of errors of the 
embryo, and others of abnormalities of the environment (intra-uterine pressure, 
&c), is in many cases easy, in others impossible. Thus polydactylism and 
congenital tumours cannot be the result of intra-uterine pressure, while 
congenital deficiency of limbs is shown to be at least sometimes due to 
constriction by the fact that the amputated limb has been found lying loose 
in utero, and in other instances the limb has been found incompletely 
severed, or even an unhealed stump has been present. On the other hand, 
the absence of the amputated limb, and the smooth, scarless appearance of 
the stump sometimes met with, may be explained by the fact that the limb 
may become disintegrated by maceration in ufero, and if the separation 
took place at a very early stage the scar might disappear during growth or 
become indistinguishable from its small size. Pressure, again, might well 
produce entire arrest of growth of a limb without amputation, and thus no 
scar would be left, while in other cases pressure might produce fusion of 
parts together, as in web fingers. 3 Evidence in favour of this is afforded by 
the coexistence of amputations with webbed fingers (both, in such cases, the 
result of pressure, though even here the webbed condition may have been 
due to mere retarded development from constriction). 

Case. — Web Fingers and Toes, dfc. — Albert B. , age 9 months ; admitted November 2, 
1885." No history of deformity or maternal impression. Left hand, second and third 
fingers are united as far as' s the first interphalangeal joint ; there is no nail on the first finger, 
a very imperfect nail on the second. Right hand, the first finger has a deep constriction 
around the last phalanx, with a bulbous enlargement of the end of the finger ; the second 
finger has a similar constriction, but the part beyond is small and almost without nail. 
There is a very deep constriction round the right leg, about one inch above the ankle, 
almost reaching to the bone. The child can stand on the leg and moves the foot freely. 
Left foot, there is only one phalanx in the great toe, and no nail ; the nail of the second 
toe is very rudimentary, and there is a small outgrowth on the fourth toe. Right foot, 
toes perfect, but the loot is hypertrophied and flat. November 5, Didot's operation on 
the hand. 7th, healing well. 12th, stitches removed ; flaps have united largely, but there 
is some granulating surface. Sent home on November 13. The flaps subsequently gave 
way partially, but were again nearly healed, when the child died at home of broncho- 
pneumonia. 



1 Vide Med. Chir. Trans. 1877 for a case of complete absence of both upper limbs 
without any scar; this was supposed not to be due to amputation. 

- Bryant records a case o\ congenital absence of the fibula, os ca cis, cuboid, and three 
outer toes. — Diseases of Children. 

3 Web fingers are, however, no doubt in most cases due to mere persistence of the 
fostal spade-like condition of the hands. 



696 Club-Foot, Deformities of Limbs, &e. 

Suppression of an intermediate segment of a limb, as where fingers are 
found springing from a stump of the upper arm, is probably due to pressure. 

Again, inherent and acquired errors may co-exist, and would be likely to 
do so. A local overgrowth of the embryo might well disturb the relation 
between the uterus and its contents, and lead to deformity by pressure. 1 

Lastly, reversion, atavism, and so on, must not be left out of sight in 
considering these questions, which cannot, however, be further discussed 
here. 2 

Whether double monsters, dermoid cysts of the ovary and testis, and 
congenital tumours of various kinds are the result of fcetal inclusion, partheno- 
genesis, or gemmation, is a question that cannot be entered upon here ; it 
will be sufficient to say that some cases are certainly the result of ' fused ' 3 
embryos — e.g. double monsters, adherent twins, and so on — while some con- 
genital tumours are equally certainly mere errors in the closing in of the 
folds of the blastoderm or of the local involutions by which certain organs 
are formed. l 

Supernumerary Dig-its are found attached in various ways ; thus, a mere 
little fleshy outgrowth with or without a nail, and with no bony support, may 



^t 



% 




h <% 




4 ' ,-.••■ 

Fig. 159. — Double Thumb. Fig. 160. — Intra-uterine Amputation of Fingers. 

be attached to a more or less normal finger, or the end of a finger may be 
bifid, with two nails. In other instances a supernumerary thumb with two 
phalanges may spring from the joint between the ' metacarpal' bone and the 
first phalanx, a common joint existing for the two thumbs, or the extra one 
may be attached to the side of the proper one. It is sometimes not easy to 
make out which is the supernumerary and which the natural digit ; in such 
cases the most useful one should, of course, be left. 

In any case of supernumerary fingers the additional one should be 
removed in infancy, so as to allow the other as far as possible to be trained 
into its proper position. Where a joint is common to the two fingers care 

1 Deficient development of one'half of the body, with facial paralysis, has been met 
with (Barker, Clin. Soc. Trans. 1884). 

2 Vide Bland Sutton's Lectures, Lancet, 1887-8. 

" ' If during development the medullary fold remains cleft, two complete foetuses are 
formed from a single ovum,' and every degree of combination from twins to very rudimen- 
tary ' parasitic ' foetuses may result. (Bland Sutton, Lancet, February n, 1888.) 

4 Numerous figures and references will be found in Forster's Missbildiinge7i des 
Menschen. 



Club-Hand 



697 



must be taken not to injure the articulation nor to allow it to suppurate, for 
fear of a stiff joint resulting. Supernumerary toes should be removed if 
they cause distortion of the foot or are likely to lead to trouble in wearing 
ordinary boots. 

For figures and details of the different forms of polydactylism we must 
refer to Annandale's work on ' Diseases of the Fingers and Toes.' 

Occasionally cases are met with where more or less of a limb is deficient, 
and the member ends in a pointed or truncated extremity like an amputation 
stump ; this may occur at any point irs the length of a limb. Sometimes 
only parts of one or more digits are deficient, sometimes the amputation has 
been incomplete, and a deep sulcus round the finger or limb, with often a 
bulbous expansion on the distal side of it, marks 
the seat of pressure. This constriction in some 
cases is so tight that there appears to be little left 
undivided except the bone, and this condition we 
have met with associated with talipes ; the move- 
ments of the limb were, however, good, and 
evidently the deeper structures, though compressed, 
were not divided. We have also seen these con- 
strictions associated with dimpled depressions over 
the knees and shoulders, and rigidity of the joints, 
also the result of intra-uterine pressure; in one 
instance there was also microcephalus. Most of 
the cases of intra-uterine amputation, and of these 
constrictions, are the result of pressure by amniotic 
bands or fcetal adhesions, as already pointed out ; 
but it is undoubtedly occasionally true that pressure 
by the umbilical cord, so gradually exerted as not 
to interfere with its own circulation, may produce 
the same effect. 1 We have not seen a case of 
constriction requiring any operation, though it has 
been suggested by Mr. Edmund Owen to pare the 
adjacent surfaces and unite them so as to obliterate 
the groove. 

Nothing, of course, can be done for congenital 
amputation except the use of prothetic appliances, 
and it is wonderful what use these patients can 
make of their stumps. As already pointed out, in 

some instances there is a distinct scar, in others a smooth unbroken 
cutaneous surface, and sometimes rudimentary digits remain attached 
to the end of a stump containing only the humerus or femur ; tjiis is 
rather an arrest of growth by pressure than a true amputation. So, too, 
sometimes the femur or humerus is congenitally very short or deficient. 
(Fig. 161.) 

Club-hand, so called, is a rare affection, resulting from arrest oi develop- 
ment of more or less of the radius or ulna, with consequent abduction or 
adduction of the hand. It is not in any sense really comparable to the 
ordinary forms of club-foot, and is little amenable to treatment. Something, 




Fig. 161. — Congenital Arrest ot 
Development of one Lower 
Limb. 



1 Vide Neville, Brit. Med. Jour. 188;, p. 209. 



698 



Club-Foot, Deformities of Limbs, 



ere. 



however, may be done by manipulation to remedy the deformity and 
possibly encourage growth of the shortened bone by friction and removal of 
pressure (fig. 162). Less often the hand is fixed in flexion or hyper- 
extension, and in these cases sometimes tenotomy maybe required. Similar 
deformities may, of course, result from cicatricial contraction after injur}-. 
In one instance the radius was entirely deficient on both sides, and the ulna 
was fractured and repaired, probably in utero. At the suggestion of one of 
our Resident Medical Officers, 
Mr. J. H. Thompson, we trans- 
planted some bone from 
another child into an incision 
between the muscles of the 
forearm. The wound healed 
perfectly, and the bone 




Fig. 162. — Club-hand/ so called. Fig. 163.— Double Club-hand. 

There is absence of the radius and 
thumb with abduction of the hand. 

growing at the time of the child"s death from an independent cause two 
or three weeks later : the position of the hand was much improved. Care- 
ful bandaging and the use of splints will do good in some cases if treatment 
is begun early. 

Web Fingers. — Various degrees of this deformity are met with : thus 
there may be a mere extension of the normal web forwards to the first inter- 
phalangeal joint. In other instances metacarpal bones and phalanges may 
be fused together, or bound in very close contact throughout the whole 
length of the digit ; occasionally the union is only at the distal ends. 1 The 
deformity is usually more or less perfectly symmetrical, and often associated 
with a. similar condition in the feet or with some other deformity. 

Where there is complete bony fusion of two adjacent digits no attempt 
should be made to separate them ; where, however, only skin and subcutaneous 
tissue unite the two fingers, they should be separated. Simple division of 
the web is of little use, since the wcund granulates up from the bottom and 
more or less reunion occurs. 

Several plans have been devised to meet this difficulty, such as applying 

1 This could hardly be the result of failure of the natural differentiation of the fingers 
in fetal life, which results from the phalanges outgrowing the webs. 



Congenital Rigidity of Joints 



699 



an elastic cord between the fingers and fastening it round the wrist after 
division of the web ; perforating the base of the web and putting a thread or 
wire through the orifice and allowing it to heal, and then dividing the web. 
Another mode consists in dividing the web and then bringing a flap of skin 
from the dorsum or palm across between the fingers so as to interpose a 
bridge of skin at the base (Norton). The best plans are the last-mentioned 
and that advocated by Didot, in which a dorsal flap from one finger and the 
web, and a palmar flap from the other finger and the palmar aspect of the 
web, are cut ; the rest of the web 
is then divided, and the flaps are 
wrapped round the raw surface of 
the finger to which they remain 
attached. In doing this operation, 
however, it will be found that there 
is not sufficient skin to cover both 
fingers, and one has to heal by 
granulation. Web toes do not re- 
quire treatment. 

Congenital Rigidity of Joints 
and Contractions. — As already 
stated, children are sometimes born 
with joints, chiefly the knees, elbows, 
and shoulders, which are stiff, or, 
on the other hand, unduly lax ; and 
sometimes these joints are fixed in 
flexion, sometimes hyper-extended, 
or at least hyper-extensible. In 
such cases there are not rarely 
marks of pressure about the joints 
— depressions and adhesions of 
the skin. Probably the conditions 
determining such deformities are 
like those causing talipes, viz. intra- 
uterine pressure or malposition ; 
thus the 'genu recurvatum' some- 
times seen results from the limbs 
being packed in hyper-extension 
along the ventral surface of the body 
(figs. 164, 165). Failure of de- 
velopmental rotation accounts 
for others. 




talipes calcaneus 

C. V. Sutton. 



together with the application o\ 
splints, as the- individual deformity may require, will sometimes effect great 
improvement ; ' in other instances little success attends treatment. 

One or more of the fingers or toes may be congenitally contracted either 
in flexion or extension ; the contraction, often slight at first, tends to increase 



looked 

was obtained. 



eley Hill records a good ra.se in which there was so much rotation that the ' 
•ectly forwards. By the use of apparatus and tenotomy .in almost perfect . 



Brit. MeJ. your. July 12, 1884 ; vide also [883. 



yoo 



Club- Foot, Deformities of Limbs, 



&c. 



as the child grows 



Hammer-toe is a result of this condition. In most 
instances it has been shown that contraction of the ligaments of the inter- 
phalangeal joints is the cause of the deformity. 

We have met with a non-congenital form of contraction of the terminal 
joints of the index and middle fingers. The skin and fascia were the structures 
affected just as in Dupuytren's contraction. According to Adams, the little 
finger is more often affected, and the deformity is said to be markedly 
hereditary, and to be commonly associated with a history of 'hammer- 
toe.' x 

Stretching and simple splints, in ordinary cases, is the treatment required. 

If neglected, troublesome 
corns or bunions and distor- 
tion of the nails may result 
from pressure of boots. 
Division of the lateral liga- 
ments, or in some cases re- 
section of a joint or part of 
the shaft of a phalanx, or 
even amputation, may be the 
best treatment for hammer- 
toe. 

' Hallux flexus,' first de- 
scribed byMr.Davies Colley, 
is defined as a ' progressive 
diminution in the normal 
range of extension of the 
great toe.'" It causes lame- 
ness, is pathologically 
closely allied to hammer- 
toe, and requires treatment 
by rest followed by manipu- 
lation and friction, and in 
severe cases by division of 
the lateral ligaments or 
osteotomy. Vide also 
' Metatarsalgia, 5 pp. 6S9- 
90. Hallux valgus and 
other deviations of the toes 
are rarely serious in children, and are usually amenable to treatment by 
splints. 

It must be remembered that some of these patients with distorted limbs 
are cases of cerebral deficiency, and for them of course little can be done. 

Congenital Dislocations, so called, of almost any joint may be met with : 
thus the temporo-maxillary, elbow, and wrist joints, the joints of the spine, toes, 
&c, have been found displaced, though such deformities are by far most fre- 
quently met with in the hip. These conditions have been variously explained : 
injury in utero or at birth, intra-uterine inflammations, convulsions, pressure, 

1 Adams, La?icct, December 13, 1890, also 1891 ; and Anderson's Lectures, Lancet, 
August 1801. 




Fig. 165. — Abnormal position in utero, causing genu recur- 
vatum and talipes calcaneus, &c, from sketch bv the late 
Mr. C. F. Sutton. 



Congenital Dislocation of the Hip 701 

nervous, bony, and muscular lesions have all been assigned, as in club-foot, as 
causes of congenital dislocations. It is most probable that, as in club-foot, 
intra-uterine pressure from malposition is the most frequent cause, though 
not the only one. In all cases more or less deformity of the bony articular 
surfaces is found, and this is of the utmost importance, since it largely pre- 
vents the possibility of anything like complete reduction. 

In ' congenital dislocation ' of the lower jaw the condyle and glenoid 
cavity, as well as much of the bony framework of that side of the skull, have 
been found stunted. Occipito-atlantoid dislocation, both backward and 
forward, has been described ; in the former 
the head is flexed, in the latter hyper-extended. 

Dislocations of the clavicle in the varieties 
met with in later life are also mentioned by 
Guerin. 

The humerus may be displaced down- 
wards, forwards (subcoracoid), or backwards 
(subspinous), with arrest of growth of muscle 
and bone, and deviation from the normal 
shape of the articular surfaces. 1 Displace- 
ments of the elbow and wrist have also been 
met with. 2 The most important of all these 
malformations is Congenital Dislocation 
of the Hip, since it is by far the most fre- 
quent, and sometimes seriously incapacitates 
the subject of it. In these cases the ace- 
tabulum is small, shallow, and may be filled 
with fat or ' webbed over ; ' the head of the 
femur may be nearly normal or much stunted. 
A more or less perfect capsule may be 
present, and this may be thickened ; or, 
again, a sort of interosseous ligament may 
exist : the ligamentum teres is atrophied, 
the muscles around the joint are wasted. 
The affection maybe unilateral or more often 
bilateral. The femur is usually freely movable 

and slides up and down upon the dorsum ilii , .^^ _ 

to an extent of sometimes two inches or Fig l66 ._< Congenital Dilation' of 

more. hoxh. Hips. Not a severe case. 

The affected limb or limbs are usually 
imperfectly developed throughout. There is always a good deal of lameness 
in severe cases, though we have met with slight degrees of this deformity 
in which the joint was not very much altered. There arc marked lordosis 
and a peculiar 'waddling' way of walking which is very characteristic. 
Usually the displacement is upwards and backwards, but it may be in 
almost an)' direction ; the limbs are sometimes adducted markedly. 




1 Dislocation 



th 



>P< 



Ik- often associated with other conditions of 



humei us 
malformation ; in a case show n uj - 

spinous dislocation o\' the shoulder ami dislocation o( both hips. See Chapter on Injuries. 
- Sec Hamilton's work on Fractures and Disloeatit 



how n us by our friend Mr. C. E. Richmond there were sub 



702 Club -Foot, Deformities of Limbs, &c. 

Besides the ungainliness of the walk, it is possible that the deformity of 
the pelvis may, as Adams suggested, be important from an obstetric point of 
view. There is little to be done for these cases, though it has been recom- 
mended that the affected limb should be supported and fixed in a state of 
•extension, and it is said that a certain amount of increased stability in the 
joint may result. 1 Section of the muscles surrounding the joint, and even 
excision, as well as scarification of the deeper tissues and hollowing out the 
surface of the ilium, have been practised with the object of giving increased 
stability to the joint, but it is unlikely that any of these plans will gain favour. 
Hoffa's mode of operating has been tried in a number of cases, but published 
results do not encourage further attempts in this direction. Prolonged ex- 
tension in bed we have found do harm rather than good, though some 
successful cases have been recorded. When the affection is unilateral a 
thick-soled boot on the short limb will improve the gait, and in some cases 
a pelvic girdle, with pads to support and fix the end of the femur, has been ox 
service. Long walks and long standing should be avoided, but we cannot 
recommend any operative treatment. The history of the case, the absence of 
pain and rigidity, and the peculiar gait distinguish the affection from hip 
disease. Rickety lordosis sometimes closely resembles congenital dislocation, 
but careful examination of the relative positions of the trochanters and iliac 
spines will prevent a mistake. The affection is by no means rare, and we have 
seen many instances of it. 

So-called Congenital Dislocation of the Knee has been already men- 
tioned as ' genu recurvatum ; this joint is also occasionally found with partial 
backward or lateral displacement. If seen in quite early infancy, these de- 
formities are fairly amenable to treatment by manipulation and splints, and 
we have been able to completely remedy the deformity of ' recurved knee ' 
by these means {vide figs. 164, 165). 

Besides the deformities already described, it is necessary just to men- 
tion the occurrence of cases of Congenital Fissure of the Sternum from 
non-union of the different centres of ossification, or rather non-closure of the 
ventral laminae, sometimes associated with ectopia cordis. Cases of deficiency 
•of the ribs over a larger or smaller area, and lack of development of the 
muscles of the chest- wall and of the mammary glands, maybe met with ; we 
Mve seen hernia of the lung through a gap of this sort. ( Vide Thompson, 
' Teratologia,' January 1895.) 

Congenital Deficiency of one or both Clavicles or of the Scapula 
may also be occasionally seen. A suprascapula has been met with, attaching 
the scapula to the vertebrae, and requiring removal (Willett and Walsham, 
* Med. Chir. Trans.' T883). Deficiency or imperfect development of the patella 
sometimes occurs ; it is usually absent in cases of genu recurvatum. Many 
•other abnormal conditions may occur— some deficiencies, some excesses, as 
in the common cases of supernumerary mammae, which are doubtless instances 
of reversion, and so on ; but these cannot be discussed here. Many require 
no treatment ; others must be dealt with on general rules. Occasionally pro- 
tective shields may be required for such cases as thoracic hernia. 

1 Mr. Adams, Brit. Med. Jour. February 1890, relates cases illustrating the value of 
prolonged extension, and figures appliances. Vide also Lovett on Disease of the Hip, 
"Boston, 1892, and papers in the Annals of Surgery, 1895. 



703 



CHAPTER XXXI 

DISEASES OF THE NOSE 

The orifices of the anterior nares are a favourite seat of eczema, lupus, and 
superficial tuberculous ulceration ; other cutaneous affections and naevi are 
also often met with upon the surface of the nose : vide Chapters XVII. and 
XXXVII. 

The nasal cavities in children are exceedingly often the seat of acute or 
chronic catarrh, the result of cold, or extension from the pharynx. Catarrh 
also commonly occurs in rickety, tuberculous, or syphilitic children. 

Acute Catarrh is generally simply mucous ; it may, however, become 
purulent, or may be so from the first, especially if it is the result of inocula- 
tion, which may occur at birth or accidentally at a later period. 

Chronic Nasal Catarrh is marked by discharge of muco-purulent material 
from the nose, swelling of the mucous membrane and of the skin of the 
anterior nares, with often some thickening of the upper lip from irritation ; 
the voice is nasal, respiration is impeded, deafness is often present, the 
child snores, and in an infant suckling is often difficult, sometimes impossible, 
from obstruction to breathing through the nose. Occasionally the inflam- 
mation extends to the antrum, nasal duct, or frontal sinuses. On examin- 
ing the nose the interior is seen to be red and angry-looking, often slightly 
excoriated ; it easily bleeds, and there are frequently dried scabs on its surface, 
while stringy mucus is apt to collect upon the lips in neglected children and 
give rise to soreness. Where one nostril alone is affected, careful search 
must be made for one of three conditions : a foreign body, such as a button, 
a bit of slate pencil, or a date-stone, &c. ; a mucous polypus growing from the 
region of the inferior or middle turbinated bone— a somewhat rare condi- 
tion in childhood ; or, thirdly, a deviated nasal septum. 

Chronic catarrh, from whatever cause, is apt, if neglected, to give rise to 
ozaena from decomposition of the retained secretion, or from caries or 
necrosis of the bones of the fossa" ; where the bones are involved the fcetor 
is more intense than in other cases. 

Should the inflammation extend to the cartilaginous and bony septum, 
the nose may lose its support, by softening of these structures, and become 
flattened and depressed. Where the outer walls are more especially 
attacked, a broad thickened nose results. In most cases these deformities 
occur in connection with congenital syphilis rather than in tubercular or 
simple bone lesions. A probe will usually detect the presence of bare bone, 
and it must be remembered that in cases of apparently simple polypi a 



704 Diseases of the A T ose 

patch of exposed bone will often be felt. Bleeding from the nose in these 
affections occurs often in small amounts, but rarely to any serious extent. 

Diagnosis. — The existence of chronic nasal catarrh is obvious ; its cause 
requires looking for, and this should be done systematically. First, if 
unilateral, the causes already mentioned — foreign body, deviated septum, 
or polypus — are to be suspected. If double, the throat should be examined 
for enlarged tonsils, chronic pharyngitis, and post-nasal adenoid growths. 
Evidence of congenital syphilis or tuberculosis may be obtained, or some- 
times simply carious teeth or eczema may be the source of the trouble. 

Treatment. — If the cause is local, an anaesthetic should be given, and the 
foreign body, post-nasal growths, &c, removed. To remove a foreign body 
from the nose, a simple loop of silver wire is useful, or a pair of dressing- 
forceps or a small scoop may be employed ; sometimes a finger passed from 
the mouth into the posterior nares is of service, and occasionally the simplest 
plan is to push the foreign body backwards into the pharynx and remove it from 
the mouth. In one of our cases the body, a button, escaped into the pharynx 
while the child was under chloroform, and was found in the vomit brought 
up by the child on its awaking. In syphilitic and tubercular cases syringing 
out with warm alkaline lotions (sodas bicarb, gr. xx ; aq. 3J), or in older 
children the nasal douche, is the most efficient means of clearing away the 
crusts ; this should be done three or four times daily, and subsequently 
powdered boracic acid or tannic acid and iodoform in equal parts should be 
blown into the nose through a quill or insufflator, or the nasal cavity may 
be brushed over with glycerine of tannin or lead lotion. Sometimes a spray 
may be substituted for the syringing after the nose is once cleared. Solution 
of hydrochlorate of cocaine, 5 to 10 per cent-, may be used as a spray or 
brushed on, either before removing a foreign body or in cases of acute catarrh. 
Cleanliness and care of the general health, with mercury or iodide of potassium, 
or both together, according to the child's age, are required in syphilitic cases. 1 
Any sequestra should be removed as early as possible, and all foul crusts 
kept constantly cleared away. Cod-liver oil and iron, with the usual hygienic 
measures and careful cleansing of the nose, together with iodoform insuffla- 
tion, is the .best treatment for the tubercular cases. Nitrate of silver, gr. 
x-xxx to 5J, is sometimes used with advantage as an occasional application. 
In nearly all chronic cases the prognosis is somewhat uncertain, and the 
course of the disease tedious. Where the above-mentioned methods fail, and 
especially in tuberculous ulceration of the nasal mucous membrane, an 
anaesthetic should be given and the affected parts well scraped with a 
Volkmann's spoon, or cauterised with the wire cautery. 

Nasal obstruction, apart from the causes just mentioned and those 
already described under Diseases of Tonsils, &c, may be due to deviation of 
the cartilaginous septum. This is sometimes congenital — more often it is the 
result of fracture of the septum, or dislocation from either the ethmoid or 
vomer, or from the nasal spine of the upper jaw ; or, again, it may be the 
result of a chronic perichondritis, following an injury, and resulting in soften- 
ing and subsequent deviation of a local patch of the septum. If the whole 

1 In infants mercury alone, in children over three or four years iodide of potassium 
alone, or, failing a good result, combined with mercury, is, we find, the most successful 

plan. 



Nasal Polypi. Ulceration 705 

cartilage is involved, there will be some flattening of the end of the nose ; 
this, however, does not usually occur. Simple chronic perichondritis, causing 
thickening, hematoma of the septum, or abscess, or even ecchondrosis 
of the cartilage may also be met with. The treatment of deviated septum 
consists in forcible straightening with a pair of guarded sequestrum forceps 
or with Adam's special instrument ; and the subsequent wearing of a nasal 
plug, such as Walsham's or the one devised by one of the present writers, is 
required. In some cases removal of the projecting mass is called for : in 
such circumstances the muco-perichonclrium should be dissected up and 
laid down again after removal of the cartilage. Hasmatoma, if it does not 
subside, is best treated by incision — so also abscess ; usually in both cases 
incision on one side will empty the sac on both sides, since the cartilage is 
perforated. Dislocation is best treated by the use of plugs. Lateral deviation 
of the nose visible externally ('crooked nose') sometimes requires the use of 
special appliances to be worn to correct the deformity. For an account of 
some cases see paper in ' Medical Chronicle,' vol. iv., 1886. 

Nasal Polypi are somewhat rarely met with in childhood ; they spring 
from the region of the middle or inferior turbinated bones as soft, grey, semi- 
transparent, rounded masses ; occasionally they take origin higher up in the 
nasal cavity. Repeated removals with the use of astringents in the intervals 
is the treatment required. 1 The polypi should be taken away with forceps ; 
in some cases the tendency to re-growth is so obstinate that it is necessary 
to take away the whole of the turbinated bone from which the growths arise. 

Where there is nasal obstruction from chronic catarrh or cicatricial con- 
traction, the use of nasal bougies or plugs smeared with any medicament 
desired, such as iodide of lead or iodoform ointment, is useful. 

Superficial Ulceration of the mucous membrane of the nose often occurs 
in cases of chronic catarrh from any cause, and occasionally the ulcers are 
deeper and lead to perforation of the septum ; this is especially likely to occur 
from pressure of foreign bodies. We have seen perforation of the septum 
occur in a child simply from picking the nose. 

Chronic 3>ry Catarrh of the nose, accompanied by atrophy of the turbi- 
nated bones and their coverings, may be met with ; it is often associated with 
ozaena. The treatment is similar to that of ordinary chronic catarrh, but, 
according to Sir M. Mackenzie, the use of medicated plugs of wool relieves 
some cases. The disease is a very intractable one ; painting with glycerine 
is occasionally useful. 

Congenital IMCalformations of the nose are rare ; closure of the anterior 
or posterior nares, adhesions between the walls of the nasal fossae, perfora- 
tion of the septum, and cases of cleft or flattened nose, or even of entire 
deficiency of the organ, have been met with.'- 

Malignant Polypi of the nose and nasopharynx arc occasionally seen in 
children ; early removal is the only treatment, but speedy recurrence is to be 
looked for. 

1 Acid, tannic, parts ii ; cupri sulphat., part i; pulv. plumbi nitrat., part .'.. will bo 
found a. good snuff lor these cases if obstinate; the mil. lor applications mentioned u 
Chronic Catarrh arc, however, often sufficient. 'I he occasional application of nitrate of 
silver fused on a wire is sometimes required. 

a For figs, of deformities vide Forster's Yfisi 



yo6 Diseases of the Nose 

Epistaxis occurs very frequently in children, sometimes as a result 
merely of cerebral congestion, the communication between the longitudinal 
sinus and the nasal veins remaining open in early childhood ; in other cases 
congestion from catarrh, or ulceration, injury, or foreign bodies, &c, may give 
rise to bleeding. Hemophilic patients frequently bleed from the nose, and 
epistaxis is a complication often met with in some of the exanthems, &c. 

Usually the bleeding ceases spontaneously in a short time ; if this is not 
so, bathing with cold water, or a little ice applied inside or over the nose, 
will usually stop the flow. Astringent powders or lotions, tannin, alum, &c, 
may be blown into the nostrils. Sometimes pressure from outside is effectual ; 
in other cases making the child stand upright, with the arms above the head 
so as to expand the chest and relieve venous engorgement, will prove suc- 
cessful. 

Occasionally the nose may require plugging. 

Nasal Deformity.— Where there is destruction of the whole or part of 
the nose, plastic operations may be employed. These must be planned ac- 
cording to the individual requirements of the case. We are rather of 
opinion that a good artificial nose is preferable to most of those obtained by 
plastic operations. Where, however, there is loss of only a small part of the 
nose, or where there is flattening without loss of substance, attempts should 
be made to improve the appearance of the child by filling up the gap or ele- 
vating the depressed part. It will be found that there is great difficulty in 
obtaining a good prominent nose by any method, and too much should not be 
promised. For details of the methods of operating we must refer to syste- 
matic works on Operative Surgery. 



707 



CHAPTER XXXII 

DISEASES OF THE EAR 

Diseases of the External Ear. — The auricle may be congenitally absent 
or crumpled and distorted : for the former condition an artificial ear may be 
fitted, for the latter usually nothing can be clone. 

In cases of deficient development of the pinna the ramus of the jaw may 
also be stunted— i.e. the first post-oral arch and its appendages may be ill 
developed. 1 

For an account of supernumerary auricles and fistulas, vide p. 169. 

Sometimes the ear is unduly large, and stands out prominently from the 
side of the head ; the appearance may be improved by the use of an ear truss, 
or in extreme cases by removal of a triangular portion of the ear and careful 
closure of the gap by sutures, or excision of a portion of the skin and cartilage 
from the posterior surface of the pinna, or by suturing the ear to the skin 
covering the mastoid process. 

The pinna is often the seat of eczema and chilblains, which require the 
treatment of the same affections elsewhere ; eczema most commonly attacks 
the crease between the auricle and the side of the head, and chilblains the 
free edge of the ear. 

Simple, lupous, or other tuberculous ulceration may also attack the ear, 
and we have seen the whole auricle rapidly slough away during an attack of 
whooping cough. 

The orifice of the external meatus is sometimes congenitally closed : in 
such cases, if the tuning-fork shows the labyrinth to be healthy, a careful 
dissection may be made at the site of the orifice, or the. meatus may be 
reached by incision behind the auricle and the orifice afterwards opened 
upon a bent probe. Nothing should be attempted until the child is old 
enough to have the healing power tested, unless there is evidence of 
retained secretion giving rise to abscess, when an opening must be at once 
made. 

The common affections of the external meatus, which in children is pro- 
portionately shallower and broader in a horizontal direction than in adults. 
are eczema, boils, accumulations of wax or epidermis, and the presence oi 
foreign bodies : the first are not peculiar to children ; the last is. of course, 
commoner in them. If the foreign body has passed beyond the orifice oi 
the meatus, it should be removed by gently syringing, or b} means of a loop 
of silver wire, or by a probe coated with cobbler's-wax or glue. No violence 

1 As in a case of Canton's, Path. Soc. Trans, vol. w. We have had similai 
under our o\\ n care. 

-• 



708 Diseases of the Ear 

should be used, and it is better to leave a foreign body where it is than to 
push it further in or lacerate the meatus or membrana tympani in attempts 
at its removal. Insects. &x., in the meatus are readily killed by a drop or 
two of oil. 

Eczema, tuberculous sores, &c, may give rise to purulent discharge from 
the ear, but usually such discharge comes from the middle ear. In all cases 
the pus should be carefully soaked up with absorbent wool and the ear 
examined ; sometimes, however, the meatus is so swollen and the child so 
intractable that no examination can be made : under such conditions the 
case should be treated as one of otitis media until, either with or without 
anaesthesia, the ear can be examined. 

The imperfect development of the tympanic bone and consequent shal- 
lowness of the meatus in children must be borne in mind ; in young infants 
the membrane lies in a more horizontal plane than in adults. 

Inflammation of the Middle Ear may be either acute or chronic. The 
causes of acute otitis are catarrh of the nasopharynx, usually associated with 
enlarged tonsils or post-nasal adenoid growths, cold, and the exanthems, 
especially scarlet fever ; injuries also, by picking or roughly drying out the 
ear with corners of towels and so on, may rupture the membrane and set up 
otitis media. 

Case. — Chronic Tonsillitis. Postnasal Adenoid Growths. Deafness. — Annie C. . age 
9 years ; admitted July i, 1884. Always healthy till scarlet fever four years ago, when 
she had sore throat, running from nose, and deafness ; worse lately. On admission, ton- 
sillar aspect ; health otherwise fair ; both tonsils bulge forwards and inwards ; nasal 
mucous membrane thickened ; upper part of pharynx stuffed full of warty adenoid growths ; 
posterior nares nearly blocked. July 24, pharynx cleared with finger, curette, and Volk- 
mann's spoon ; left tonsil removed, bled freely ; much clearer afterwards. Result, great 
improvement. February 1885, quite well. 

Sir W. Dalby l has pointed out that boxing the ears of children may 
give rise to nervous deafness without a rupture of the membrana tympani, 
such deafness being usually permanent and severe ; or the membrane may be 
ruptured : in such case the rupture may heal or be followed by inflammation 
of the middle ear ; or, lastly, acute otitis may be set up without rupture of 
the membrane. 

In otitis the result of throat affections the disease may be caused either 
by Eustachian obstruction, and consequent retention of secretion, or by actual 
extension of the inflammation along the tube. The symptoms are pain in 
the ear and head, deafness, and some constitutional disturbance. In infants, 
who cannot indicate the seat of their trouble, otitis should be suspected if 
there are fretfulness and restlessness, with tossing about of the head without 
other assignable cause. If these cases are left to themselves, the membrane 
soon yields, and a purulent discharge escapes from the meatus, giving 
usually great relief; until discharge appears the condition is often overlooked 
in scarlet fever, where the attention is apt to be directed to other symptoms. 
If the membrane is examined in such cases, there will be seen all the signs 
of inflammation, redness and loss of lustre, and if pus is present it may 
• perhaps be visible as a yellow discoloration of the lower part of the mem- 
brane. 

1 Brit. Med. Jour. December 23, 1882. 



Otitis Media yog 

Treatment. — The throat must be attended to, and antiseptic, sedative, or 
astringent applications used, according to circumstances ; next, the Eustachian 
tube must be kept open by Politzer's method : the inflation can be performed 
at the moment of the child's crying. Hot fomentations, with perhaps a leech 
behind and in front of the ear, and instillation of a drop of glycerine and 
laudanum, or glycerine and carbolic acid, into the meatus, should be employed. 
Failing relief by these means, the membrane should be carefully incised, 
either horizontally or vertically, behind the handle of the malleus, and the 
discharge allowed to escape — gentle washing out of the ear with warm 
boracic lotion, and inflation of the middle ear, being also used. As soon as 
the acute symptoms have passed off, powdered boracic acid and iodoform 
should be blown into the ear after drying it carefully with absorbent wool 
two or three times daily, according to the amount of discharge. 

The dangers of otitis media are manifold : first, deafness ; and secondly, 
extension of inflammation, which may reach the mastoid antrum or the 
mastoid cells, perforate the roof of the tympanum, or the sutura petro- 
mastoidea, which is still open in infancy, and so directly reach the brain. 
Cerebral abscess and meningitis are not remote dangers. Or the carotid 
artery may be opened by ulceration and fatal bleeding ensue ; or throm- 
bosis of the lateral sinus and pyaemia may result. Extension of mischief 
to the temporo-maxillary joint may occur, with stiffness of the articulation. 
The amount of deafness depends rather upon the injury done to the laby- 
rinth, upon interference with the mobility of the ossicles, or upon fixation of 
the stapes, than upon destruction of the membrana tympani. 

The dangers to life are to be met by providing free drainage for discharge 
and keeping the cavity aseptic as far as possible. If there is any pain, 
swelling, or tenderness over the mastoid process, an incision should be at 
once made down upon it ; if no pus is reached and the symptoms are urgent, 
the bone must be carefully gouged away just behind and level with the roof 
of the meatus until the cavity of the antrum is reached. It must be remem- 
bered that in children the mastoid cells are not well developed and van- 
much in size, and that the lateral sinus descends less than half an inch 
behind the meatus. Swelling and tenderness over the mastoid process 
does not always mean inflammation of the mastoid antrum or cells, but may 
be the result of extension superficially of inflammation from the meatus. 
Even if pus is not reached at the time, relief may be given and an easier 
way for discharge made ; but the removal of bone should be free if the 
symptoms are definite, and, if possible, an opening should be made through 
which lotion can be syringed into the external meatus. Lane advises 
removal of the whole of the outer wall of the antrum. 1 In neglected case- 
extensive necrosis may occur, and the walls of the meatus, or even the 
greater part of the petrous bone, may come away as sequestra. It is 
common to find the lymphatic glands just below the ear inflamed, and they 
may cause much pain, or may suppurate and discharge through the walls o\ 
the meatus. In the early stages of glandular inflammation hot belladonna 
fomentations will often arrest the mischief ; if suppuration occurs, the abscess 
should be early incised. Suppurative meningitis, if diffuse, is not amenable 
to treatment, but localised cerebral abscess, which may be either in the 
1 Brit. Med, your. March [890 and June 1890. 



7 1 o Diseases of the Ear 

temporo-sphenoidal lobe or cerebellum, should be treated by trephining the 
skull and opening the abscess {vide p. 467 et seq.). 

Facial paralysis, which not uncommonly results from otitis media, is 
peripheral, and the result of pressure upon the nerve in the wall of the 
tympanum ; thejparalysis usually disappears on subsidence of the otitis, but 
may be permanent. Chronic otitis media may be due to the same causes as 
the above, but is often tuberculous ; it may last for years, and give rise to 
occasional attacksjof acute earache. Chronic otitis is always a source of 
danger, and should never be neglected ; the tympanic cavity should be care- 
fully cleansed by gentle syringing, and then the mucous membrane got into 
a healthy state by insufflation daily of the iodoform and boracic powder, or 
by the use of slight astringents, such as alum, gr. iij to ^j, or sulphate of zinc, 
gr. j-ij to 3J ; boracic and carbolic lotions are perhaps the most generally 
useful. On examination of the ear in these cases the membrane is usually 
almost entirely gone, and the ossicles more or less completely destroyed ; the 
hearing power is impaired, but seldom entirely lost. The complications met 
with in the acute variety are also liable to occur at any time in the course of 
a chronic case. Small perforations of the membrane in children readily 
heal, but it is exceptional to meet with them. 

In very chronic otorrhcea masses of granulation tissue, springing from the 
tympanic cavity, less often from the membrane or walls of the meatus, may 
appear, and form the commonest kind of aural polypus ; fibrous, mucous, and 
adenomatous polypi are much rarer. Polypi are to be treated by removal 
with forceps, or scraping away, and the application of some caustic, of which 
we prefer solid nitrate of silver fused on a loop of wire ; crystals of per- 
chloride of iron or chromic acid may be used if preferred, and the ear should 
be washed out with a solution of rectified spirit as strong as can be borne 
without pain (usually 1 in 4 to 1-2 can be employed). Boracic and tannic 
acid and iodoform insufflations should be used between times. It is often 
necessary to remove these polypi several times before they cease growing. 
All abscesses burrowing about the ear must be opened and well drained, and 
the general health, as well as the condition of the throat and nose, carefully 
looked after. Eustachian catheters require an anaesthetic in children, and 
should only be used when Politzer's method fails. 

The general routine method, then, of treating otorrhcea ('otitis media 
suppurativa') may be given thus. (1) Dry out the ear with absorbent 
wool. 1 (2) Examine with a speculum, and through this puff a powder of 
equal parts of iodoform and boracic acid, once, twice, or three times daily, 
according to the amount of discharge.' 2 (3) Inflate the ear by Politzers 
method once daily. (4) Watch for, and open early, any mastoid or glan- 
dular abscess. (5) Protect from cold, and take care of the general health. 3 
(6) Never neglect the least earache. (7) See that the throat and naso-pharynx 
are healthy. 

1 Where hospital patients cannot be seen daily the friends should syringe out the ear 
with warm boracic lotion. 

- We prefer a simple speculum and the use of an aural reflecting mirror, but Brinton's 
' otoscope ' may be used. 

3 A clean plug of absorbent wool should be put into the meatus and changed two 01 
three times daily or more, according to the amount of discharge. 



Intracranial A bscess 7 1 J 

It must be remembered that pain in the ear may be a result of carious 
teeth, cervical adenitis, or any source of pressure upon the nerves supplying 
the auricle or meatus, as well as of ear disease. 1 

Affections of the labyrinth in children may be either congenital, or the 
result of injury, or of extension from otitis media, or of congenital syphilis. 
The latter form usually comes on about the seventh to twelfth year, increases 
rapidly, affects one ear first, and leads to severe or total deafness ; it is 
rarely remediable, though mercury and iodide of potassium should be tried. 
If the case comes under treatment in an early stage, there is some hope of 
recovery. Deafness in children should be seen to at once, and care should 
be taken, in those in whom restoration of hearing cannot be complete, to 
make them read and speak aloud to prevent the tendency to become mutes. 
Deaf-mutes should be taught the 'oral method.' 

Intracranial Abscess. — Should there be evidence of intracranial abscess, 
as shown by fever, vomiting, otorrhcea, pain in the side of the head, convul- 
sions, squint, hemiplegia, more or less loss of consciousness, and perhaps optic 
neuritis, the ear should be examined and well cleaned out, so as to avoid 
any further retention of pus in the tympanum ; a flap of soft parts should then 
be turned up by a curved incision, exposing the temporal bone above and 
behind the ear ; a circle of bone should then be gouged away, having its 
centre opposite the posterior superior quadrant of the meatus, and from \ in. 
to \ in. from the meatus, according to the age of the patient. 2 Having removed 
the bone, if no sign of abscess appears, the dura mater should be incised and 
the brain punctured first directly inwards, then forwards and inwards, and 
finally backwards, so as to tap any abscess situated either in the cerebrum 
or cerebellum ; if pus is found, the opening should be enlarged, and the 
abscess drained and treated on general principles. The mastoid antrum 
and cells, if not previously cleaned out, should be dealt with at the same time. 
{Vide also p. 467.) Barker points out that a single rigor, followed by sub- 
normal temperature, slow pulse, and ' sluggish, but perfect, cerebration,' may 
be met with in cerebral abscess. There appears to be no certain means of 
distinguishing temporo-sphenoidal from cerebellar abscess, but in the latter 
the pain is usually occipital, and there is retraction of the head ; the amount 
of paralysis in either case is inconstant. Temporo-sphenoidal abscess is 
about three times as common as cerebellar according to Barker, who sum- 
marises the whole question in a valuable paper in the Lancet for June 11, 
1887. He also believes that abscess in the brain is much rarer than meningeal 
or subdural suppuration. 

Not very long ago we had under the care of our colleague Dr. H utton and 
ourselves, a boy eleven years old, suffering from double otitis after small- 
pox. On admission there was discharge from both ears, with pain in the 
left, and in the left temple. Shortly after entering the hospital he had 
a succession of rigors. The ears were full of thick discharge, and each 

1 / '/'(/,' Hilton's Rest and Pain. 
Barker gives \ in. above and \ in. In-hind the centre oi the bony meatus f< 
dura! abscess over the roof of the tympanum, and h in. directly behind the meatus for sub- 
dural abscess in the groove of [he lateral sinus. By enlarging tin- opening upwards and 
backwards, .wu\ then puncturing the dura mater, avoiding the lateral sinus, any abscess 

in tin- brain would probabh be reached. 



712 Diseases of the Ear 

contained a small polypus. The ears were cleaned out, the polypoid granu- 
lations removed, and the acute symptoms disappeared. There was no 
mastoid trouble. A week later the boy became drowsy, with a subnormal 
temperature ; there was no paralysis, no spasm, except possibly of the 
muscles of the left side of the face, but this was probably rather paresis of 
the right side. Slight cloudiness of the left optic disc was found ; there was 
no apparent tenderness. The next clay a circle of bone was removed from 
above and behind the meatus, the dura mater opened, and the brain explored 
systematically, but no abscess was found in the temporo-sphenoidal region. 
A second flap of skin was then turned upwards from the occiput, and a 
small aperture made in the skull ; a trocar was then passed downwards 
through the tentorium into the cerebellum, and offensive pus escaped ; the 
cannula was left in, but the boy died, apparently of shock, six hours later. 
From examination of the head we should advise in such cases the removal 
of a circle of bone immediately above the external auditory meatus, at a 
distance from it varying from \ in. to I in., according to age ; the dura 
mater should then be stripped back until the roof of the tympanum is 
exposed, and any pus lying there evacuated. Next, the dura mater should 
be incised and the brain explored, first directly inwards, in the posterior 
part of the temporo-sphenoidal lobe, and, failing this, backwards, inwards, and 
downwards, and finally forwards. Either a temporo-sphenoidal or cerebellar 
abscess would probably be thus reached. If, however, the symptoms are 
fairly definite and no abscess is found in this way, the skull should be opened 
midway between the superior and inferior curved lines of the occipital bone, 
and the cerebellum explored. It is readily reached in this position. 

It should be remembered that a cerebral abscess may be latent — i.e. may 
exist and give rise to few or almost no symptoms — and yet may cause sudden 
death. 

In the above case there were no definite symptoms to point to cerebellar 
rather than to temporo-sphenoidal abscess, and it was only, failing the 
latter, that, feeling strongly that an abscess existed somewhere, we sought 
it in the cerebellum. (Vide also Cerebral Abscess.) 

In cases of tuberculous otitis we have been in the habit of freely scraping- 
out the middle ear with a Volkmann's spoon, removing all cheesy bone and 
granulation tissue with or without a mastoid incision, according to the extent 
of the disease. The scraping should be thorough, and should be repeated if 
necessary. 

Where symptoms of septic absorption and thrombosis of the lateral sinus 
and internal jugular vein exist, the vein should be exposed and ligatured, 
and then together with the sinus laid open and cleaned out. Similar con- 
stitutional symptoms with orbital swelling and proptosis would indicate 
thrombosis of the cavernous sinus, which occasionally occurs, and might 
possibly be reached by operation through the orbit, though we are not aware 
that this has been hitherto attempted. ( Vide p. 483.) 

Note. — In examining the tympanic cavity post mortem, it should be remembered that 
the presence of a puriform fluid in the middle ear of infants is common, and apparently 
rather the result of the changes that take place after the entry of air into the tympanic 
cavity than pathological. 



713 



CHAPTER XXXIII 

TUMOUR GROWTH IN CHILDHOOD 



Tumour Growth in Childhood. — As might be expected in a rapidly 
growing organism, the connective-tissue group of tumours is that almost 
exclusively met with in children. Sarcoma, myxoma, enchondroma, and 
osteoma are the common forms of new growth, and these are usually in an 
embryonic and therefore unstable 
and rapidly growing form. Soft (en- 
cephaloid) carcinoma is occasionally 
met with, it is said, especially in the 
eye, kidney, and testicle ; but it is 
probable that most of the so-called 
carcinomata are really sarcomata. 1 
Our colleague, Dr. Hutton, had 
under his care a child with an 
enormous tumour of the kidney, 
which proved to be a columnar epi- 
thelioma. - 

Sarcomata are not rare in chil- 
dren ; they are commonly of the small 
round-celled or mixed varieties, are 
most often seen as periosteal growths, 
and often follow injuries. They are 
met with in connection with the jaws, 
the skull, and the long bones, most 
commonly grow rapidly, early become 
generalised, and are speedily fatal ; 
we have met with rapidly growing 
sarcoma as a sequel of acute peri- 
ostitis. 

The eye :1 and the skin are not 
rarely the seat of sarcoma ; we have 

seen a melanotic spindle-celled growth in the skin ot the dorsum o\ the 
foot. The kidney is occasionally the subject of congenital sarcoma 
Chapter on DISEASES or Tin: KIDNEY). 

1 These are also common sites for sarcomata in childhood. - Vide tic. na, 

■' As in tin- following case, figured above (fig. 167) : — 

Sarcoma of Eye and yaw, &"e. — Walter \Y., age 1 year 7 months ; admitted Jul) 38, 
1884. At birth, in the Left eye it was noticed that the pupil was white : three months 




ig. 167.— Sarcoma of the Lower Jaw and Eye- 
ball in a child aged 19 months. 



7H 



Tumour Growth in Childhood 



Where sarcomata occur in the limbs, early amputation is the only treat- 
ment ; in the case of renal growths the balance of evidence is against any 
operation. Testicular tumours should be removed as soon as they are 
recognised, and growths in other situations must be treated as the individual 
case may require. 

We have met with a Neuroma only once in a child, and the case is of 
sufficient interest to be worth recording in detail. 

Neuroma of Posterior Tibial Nerve. — Alice M., age n years ; admitted May 9, 1885. 
Healthy girl. Three years ago first complained of pain in the right ankle and walked 

with a limp. Has been getting worse 
la'ely, and the ankle has become more 
tender. On admission there is much 
tenderness along the inner side of the 
ankle, extending for about \\ inches 
up the leg. There is swelling and 
some heat over the painful area, which 
seemed to correspond to the tendons 
of the tibialis posticus and flexor longus 
digitorum. The case was thought to 
be one of tenosynovitis, and the child 
was sent out in a plaster-of-Paris splint 
on May 20. Readmitted November 5. 
Condition unaltered ; much pain and 
tenderness. November 23, the limb 
was rendered bloodless and an incision 
made over the swelling in its whole 
extent, when a firm, pale, lobulated 
tumour was found connected with the 
posterior tibial nerve ; the growth was 
encapsuled an d turned out fairly freely ; 
it reached from the middle of the leg 
to nearly the middle of the inner side 
of the foot, and was about the size of 
two average fingers. The nerve was 
inextricably involved and ran through 
it. The whole tumour and the nerve 
were removed, about 5 inches of the 
latter being taken away. No large 
vessel was injured, but there was 
troublesome bleeding from some small 
ones. She did not bear the operation 
well. P'or some days she had hyper- 
aesthesia of the opposite limb. The 
wound healed well, but somewhat slowly. On December 2 it was noticed that ankle- 
clonus was well marked. On the 13th the whole sole of the foot nearly to the root of the 
toes was completely anaesthetic, as well as almost the whole of the plantar surface of the 

the eye began to swell ; three weeks ago the right half of the lower jaw began to enlarge 
painlessly and to grow rapidly in size. No cause known. On admission, well nourished. 
The left eyeball was enlarged and protruded ; it was irregular in shape and reddened ; 
the cornea was vascular. The lower part of the right side of face much enlarged ; large 
veins on the surface, which was nodulated ; swelling involved whole thickness of hori- 
zontal ramus of jaw, projecting outwards and into mouth, which could not be closed. 
Teeth displaced and loose; no ulceration; no disease elsewhere. August 1, swelling 
increasing rapidly, not much pain, losing flesh. Discharged August 12, and died at home 
a few weeks later. 




Fig. 



-Enchondroma of Cervical Spine and Fingers. 



Enchondroma 



715 



little toe. The sides of the foot, the ball of the great toe, and to a less extent the balls of 
the second, third, and fourth toes, together with the whole of their plantar surface, were 
partially anaesthetic. Sensation elsewhere normal. The calf muscles somewhat wasted. 
In January 1886 she was practically as on discharge, tut could walk a little and move the 
foot freely without pain. Nutrition of foot good. Microscopically the tumour was a 
myxo-fibroma. Nerves could be traced for some distance in it and then became 
degenerated and lost. March 23, 1888, quite well ; no return of sensation ; foot warm ; 
arch good ; walks well ; no pain or tenderness. 

Of the more innocent growths the Enchondromataare the most common ; 
they are usually multiple, occur on the fingers, and may be congenital ; they 
tend to grow with more or less rapidity, and if they cause inconvenience may 
require amputation of one or more fingers. Removal of the growth alone 
is rarely satisfactory, since it has been shown that the tumour is very often 
central in origin, as in the following instance : — 




Fig. 169.— Multiple Enchondromata of the Forefinger. 



Multiple Enchondromata of the Fingers. — Samuel M., age 7 years 9 months ; admitted 
January 28, 1885. When five months old swellings were noticed on the fore and middle 
fingers of the left hand ; these have gradually increased, and give rise to much pain if 
injured ; at other times they are painless. On admission, is a thin, unhealthy boy. Several 
cartilaginous masses are growing from all the fingers of both hands ; the swellings vary 
in size from a pea to a small nut, the largest is in the flexor aspect of the left middle 
finger ; this finger cannot be flexed. The fingers are large and distorted, with some 
lateral deflection of the second and third fingers of the right hand. The worst, the left 
middle finger, was amputated at the metacarpophalangeal joint, and the theea was 
stitched up with catgut (Treves). A section of the finger showed a cartilaginous tumour, 
the size of a small walnut, growing from the proximal end and from the central part of the 
epiphysial line of the second phalanx. The flexor tendon was stretched over the tumour. 
A. smaller mass sprang from the distal end ofthesame phalanx. The wound soon healed. 
The other lingers were not touched, as they gave rise to no great inconvenience, 
cervical vertebras were similarly affected {vide tig. 108). 



1 6 



Tumour Growth in Childhood 



Another case is shown in fig. 169. Osteomata are usually sessile, com- 
posed of cancellous tissue capped with soft cartilaginous or myxochondro- 
matous tissue ; they most frequently spring from the neighbourhood of an 
epiphysial line, may be multiple, and are occasionally hereditary. These 
growths may require removal on account of their interference with the 
movements of a joint or of pain ; if chiselled or sawn through at the base, 
they do not recur. We have most often seen them at the upper end of the 
humerus, as in the case quoted. 

Exostosis. — Sarah E. T. , age 10 years 6 mon'hs ; admitted January 9, 1884. Tumour 
first noticed six weeks ago ; has grown slightly since ; no cause known. On admission 
an exostosis as large as a good-sized walnut was found on the posterior aspect of the 
humerus, 2 inches below the acro- 
mion ; the swelling was bilobed. 
Removed by chisel antiseptically on 
January 17 ; the surface was cartila- 
ginous, the deeper part composed ot 
cancellous tissue. Wound healed on 
January 22. 





Fig. 171. — Congenital Serous Cyst of the Back. 



Fig. 170. — Hygroma of the Neck, asso- 
ciated with Microglossia. Mr. White- 
head's ca^e. The tongue is protruding. 
Vide also Naevus. 

Besides the growths already 
mentioned, there is the large 
group of Congenital Fibrous 
and Cystic Tumours : the 

former may occur in any part, 
the latter are said to be limi- 
ted to the trunk and head ; 
we have, however, removed a 

multilocular cystic growth from the back of the thigh in a child. 1 Cystic 
hygroma of the axilla is not very uncommon ; it usually extends up into 
the neck. The cystic tumours may be divided into several classes. A 
large proportion are really cavernous lymphangiomata (lymph naevi) ; such 
are hygroma, hydrocele of the neck (a unilocular hygroma), the tumour 
mentioned above as removed from the thigh, and many others. In the 
second group are those cystic tumours resulting from degeneration of a blood 
naevus ; in these the fluid may be clear, or more or less stained by admixture 
of blood pigment. The third group includes cystic formations by degenera- 



1 Morgan has recorded a hygroma of the thigh in the Clin. Soc. Trans. 1884. 



Dermoid Cysts 717 

tion in fibrous or teratomatous growths ; and the last includes dermoid cysts, 
the result of involuted or ' dissociated' blastoderm. 1 

These 'dermoid' cysts may be met with in the course of any of the lines 
of union of the embryo, e.g. along the median ventral and dorsal lines of the 
trunk in the face, head, palate, neck, 
&c. These cysts are due to closing 
in of the tissues over a portion of 
epiblast ; hence the cyst wall is com- 
posed of more or less perfectly 
formed skin, with hairs, sebaceous 
glands, &c. ; lying in the cavity of 
the cyst will be found sebaceous 
matter and hairs, and epidermic 
scales. Perhaps the commonest 
sites for these tumours arte the 
outer angle of the orbit (orbital 
fissure), the inner angle (lachrymal 
fissure), and the median ventral 
line. In the auricle they may 
result from inclusion of skin be- 
tween the tubercles by fusion of 
which the auricle is formed. They 
are sometimes met with in the 
middle line of the nose, and cause 
much disfigurement by the growth 
of hair from their interior ; in this 
position they must be due, as 

pointed out by Bland Sutton, to some irregular laying down of the skin 
there is no line of fusion in the development of the embryo at this spot, 
bably the growth of the nasal bones and lateral cartilages causes some inversion 
of the skin. The growth of hair seen upon the nose in later life suggests a 
possible similarity between the two conditions. 

Dermoid cysts differ from acquired sebaceous cysts in that they are con- 
genital, that they lie deeper than the ordinary wen, being in the subcutaneous 
or even in the submuscular tissues, and in the case of the skull they may 
cause partial or complete absorption of the underlying bone. The skin over 
a dermoid cyst is usually of natural appearance and of normal thickness, not 
thinned and showing dilated capillaries, as is often the case in sebaceous 
cysts. In sebaceous cysts the aperture of the gland is often visible as a black 
speck : no such mark is seen in a dermoid tumour. Should the dermoid cysts 
grow and become unsightly, they should be excised, but it must be remem- 
bered that their removal may be dangerous on account of their deep 
relations, and that, as they are lined with more or less perfect skin, complete 
removal is required, and it is not sufficient to lav open and scrape the cyst 
wall. 




Dermoid Cj-st of Orbit. 



since 
Pro- 



1 The relations of congenital ' displacements' to subsequent tumour growth cannot, of 
course, be discussed here; probably onlj a small number of casesare to bo thusaa 
for {vide Cohnheim ; also Eve'-. 1 ectures at the Roy. Coll. o\ Surgeons, [883, ani 
Sutton's Lectures on Evolution in Pathology, Brit. Med. Your. r88o. 



7 i8 



Tumour Growth in CJiildlwod 



Mr. Bland Sutton, in his lectures delivered at the Royal College of Surgeons, classifies 
dermoid tumours as (i) Sequestration dermoids ; (2) Tubular dermoids; (3) Ovarian 
dermoids. 

The first occur usually in the lines of union of the embryo, or are a result of accident 
a sort of subcutaneous grafting of dermal tissue. 

Tubulo-dermoids arise in connection with ' obsolete canals ' ' associated with the primi- 
tive alimentary canal.' They may exist as 'dermoid cysts,' 'dermoid tumours,' or as 
'thyroid dermoids,' or 'congenital adenomata.' 'The first two varieties do not differ 
from sequestration dermoids, except that they are more complex.' Mr. Sutton calls them 
thyroid dermoids because of their histological resemblance to the thyroid body. ' They 
present easily recognisable characters : (1) they arise in obsolete sections of the gut ; 




Fig. 173. — 'Dermoid' Cyst of the Forehead. Mr. Hardie's case. 



(2) resemble structurally the thyroid body ; (3) are frequently associated with striped or 
unstriped muscle fibre; and (4) are usually congenital.' 'The most typical specimens 
occur in the neighbourhood of the coccyx, in the tongue, and in the neck.' 1 

After further details, for which we must refer to the ' British Medical Journal,' March -z t 
1889, whence the above extracts are taken, Mr. Sutton concludes his most interesting 
accounts of these curious growths by remarking : ' It is an interesting fact that the six 
obsolete canals existing in the embryo of a mammal, namely, the infundibulum, neuren- 
teric passage, post-anal gut, cranio-pharyngeal canal, thyreo-lingual duct, and the duct of 
the yolk sac, should all have direct relation with the alimentary canal, and each be directly 
associated with dermoids, often of considerable complexity, and with a peculiar form of 
tumour, identical in structure with the thyroid body.' Quite recently we have met with a 
case of an infant, a twin three days old, who was the subject of a large unilocular cystic 



Vide also Marshall, Jour. Anat. and Phys. vol. xxvi. 



Fatty Tumours 



Jig 

tumour growing from beneath the coccyx, and forming a somewhat pendulous mass 
hanging from the perinceum. The cyst was thin-walled, and about the size of the child's 
head. A day or two after admission the cyst burst, and gave exit to about half a pint of 
clear yellow fluid — practically serum. We removed the collapsed cyst by excision, and 
found a fine channel running up into the pelvis for about \\ inch. The child did well, 
and was sent out with the wound nearly healed in March 1889. Sections of the wall ot 
the cyst showed a distinctly villous lining, with a single layer of somewhat indistinct 
roundish cells. 

Vide also chapter on Malformations of the Digestive Apparatus, 

An important group of tumours in childhood is formed by the fatty 
growths often met with. There may be simple general obesity or hyper- 
trophy of fat, a condition often met with in our experience in association 
with malformations such as club-foot, spina bifida, giant foot, &c. 1 Jacob 2 




Fig. 174.— Dermoid Cyst in the. Lachrymal Fissure. A tooth is seen 
growing at the upper part of the tumour. Prof. Young's case. 

who has collected many of the cases on record of hypertrophy of the 
extremities, attributes the condition to intra-uterine venous congestion :; in 
early fcetal life ; if, however, this occurs before the first half of intra-uterine 
life, during which no fat is said to be formed, myxomatous tissue is developed ; 
if in the later stages, fatty tissue. 

Lipoma may occur in any part of the body ; it is, however, rarely nun 
with in the head. Congenital lipomata are often not encapsuled ; they are 
sometimes associated with nsevus, as in fig. 60 (naevus lipomatodes), or, as 

1 The cervical fatty growths met with in cretinsare also noteworttrj in this connection. 
- Archives of Pediatrics, February 1884. Jacobi's list contains obviousl} very different 

pathological conditions. Also Bland Sutton, Brit. .!/<•</. your, vol. i. 1890, p. 877. 
5 Busey attributes it to lymph stagnation. 



20 



Tumour Growth in Childhood 



in one case of Jacobrs, with spina bifida. Congenital sacral tumours are 
sometimes mainly fatty, as in one or two of our own cases ; but these, and 
indeed congenital iipomata elsewhere, are by no means always pure fatty 




-Congenital Myxc-Lipoma of the Breast. The tumour was removed, and the child 
did well. We have lately seen a second similar case 



growths ; fibrous, bony, or cartilaginous material may be mixed up with the 
fat, as well as naevus, muscular tissue, 1 &c. ; these more complex tumours 
belong to the teratomatous class rather than to the ordinary Iipomata. 

When occurring in the foot congenital 
lipoma forms one of the varieties of 
so-called ' giant foot,' of which fig. 176 
is a specimen ; in some of these cases 
the growth is encapsuled ; in others it 
is diffuse, and after incomplete removal 
it shows a tendency to recurrence. In 
these cases of giant limb, which are 
usually unilateral, the rate of growth 
is variable, and all the constituents of 
the limb are overgrown in some cases, 
while in others the bones are enlarged, 
the vessels, muscles, and nerves being 
normal. 2 (See also chapter on NAEVUS, 
p. 349, for an account of the lymphatic 
form of ' giant foot. ; ) 

Fatty tumours of doubtful con- 
genital origin are sometimes met with, and may be the seat of myxomatous 
change, as in the appended case. 




Fig. 176.— Giant Foot (the Fatty Variety), the 
growth affectins mainly the toes, but also to 
some extent the sole oi the foot. 



1 Vide Butlm, St. Barth.'s Reports, 1877. 

2 Vide Anderson, St. Thomas's Hospital Reports, 1881 ; Barwell, Clin. Soc. Trans. 
1884; Blackader, Arch, of Pediatrics, Oct. 1S8; ; Esmarch and Kulenkampff, Die 
elephantiastischcn Formal, Hamburg, 1805. 



Compound Congenital Tumours 



721 



Case. — Congenital (?) Myxo-lipoma of Thigh. — William M. , age 2 years ; admitted 
November 2, 1885. Child began to walk last January, but was weak and soon tired ; 
had a severe fall at that time. Four months ago a swelling was first noticed at the back 
of the left thigh; it has gradually increased in size, but has never been painful. Has 
been wearing splints for rickety deformity lately. No sores about the legs. On admission, 
a very rickety child. In the middle of the back of the left thigh is a soft movable swel- 
ling, not tender, not well defined, and indistinctly fluctuating (?). The swelling is about 
the size of a large walnut or larger. November 5, an incision was made over the swelling 
between the hamstrings ; it was found to project on the inner side of the great sciatic 
nerve, and was, with some dissection, shelled out from its deeper attachments to the 
superficial layer of periosteum ; it extended from the upper border of the popliteal space 
upwards for about 2^ inches. The whole growth was removed ; it was fairly well en- 
capsuled, soft, and gelatinous. Microscopically it proved to be a myxo-lipoma. On 
November 16 all stitches were removed and the wound was almost healed. Sent home. 




Fig. 177. — Congenital Cystic Tumour of the Groin. Mr. Hardie's case. 



Compound Congenital Tumours occur most frequently about the sacral 
and lumbar regions ; their origin is obscure, and has been accounted for on 
the view of included fcetation, gemmation, or inclusion of a portion of the 
outer layer of blastoderm, at the time of closure of the dorsal laminae. 3 The 
tumours are often cystic, and may contain masses of fat, cartilage, bone, and 
skin elements. They vary in size, and may attain great dimensions : their 



1 Mr. Bland Sutton divides these tumours into 1'onr classes : 1. Sacral spina bifida ; 
2. Tumours originating in* the postanal gut; 3. Cystic tumours originating in the 
neurenteric canal ; 4, Parasitic foetuses.— -Erasmus Wilson. Lectures. Brit. Med. 
February 12, 1887. 

\ A 



Tumour Growth in Childhood 




722 

rate of growth usually corresponds with that of the child ; they may become 
ulcerated from irritation. Such tumours give rise to trouble by their weight 
and bulk, and their interference with movement. 1 

Case..— Congenital Sacral Tumour.— EXizth. Ann T., age 4 years; admitted February 
2, 1885. Always a delicate child ; more so since an attack, of scarlet fever at two years. 
The tumour has gradually increased to twice the size it was at birth. She has had no fits ; 
vomits frequently after meals ; cannot retain her urine, but has no incontinence of faeces ; 

sleeps badly and complains of abdo- 
minal pain. On admission, a delicate 
child. Over the lower lumbar and 
upper sacral vertebras is a soft, pulpy 
tumour, about the size of a small 
orange ; the skin is natural over it ; 
there is no tenderness on pressure, and 
the swelling is not fluctuating. There 
is loss of power in both legs ; the child 
can draw them up in bed, but cannot 
support herself upon them. February 
13, the tumour was explored with a 
needle, but no fluid was found ; a 
straight incision was then made over 
the swelling and the skin reflected, 
exposing a mass of fat. On dissecting 
this carefully away a small tumour the 
size of a filbert was exposed ; this 
evidently contained fluid and could be 
seen to pulsate ; it clearly was con- 
nected with the theca ; this was left 
uninjured, and the fatty mass dissected 
away from it. The wound was drained 
and sutured ; operation antiseptic. 
On making a section of the growth a 
small nodule of cartilage was found 
in its centre. February 14, dressed ; 
about half an ounce of blood-stained 
serum escaped ; child vomited once, 
otherwise well ; no convulsions or 
pain ; tube removed. 15th, was sick 
twice yesterday and awoke several 
times in the night, screaming. 16th, sick 
again yesterday ; no more screaming ; 
lies very quiet. 18th, dressed ; a quantity 
of serum collected beneath the skin, so 
tube was put in again ; has been very 
irritable for last two days ; sick once in 
no squint or 'convulsions ; temperature 




178.— Congenital Sacral Tumour with Talipes. 



the night ; slept well ; ice to head and spine 

normal. 19th, is a little better. She became steadily worse, and died on the 21st 

with evidence of meningitis. The highest temperature was 99 "2°. 

Post-mortem. — On removing the brain an excess of fluid escaped ; the surface of the 
brain was congested, but otherwise natural ; there was some matting together along the 
Sylvian fissure, but no other abnormal appearance. Spinal cord, excess of fluid and much 
congestion at the seat of the tumour and for four inches above it. The cord ended in a 



] Vide Clin. Led. by James Hardie, F.R.C.S., Lancet, May 2, 1885. Into the subject 
of teratology it is impossible to enter here, but the reader may refer, among other works, 
to Forster's Missbildungen des Menschen. 



Congenital Sacral Tumours 



723 



fibrous expansion which spread out over the tumour. Small portions of the tumour ex- 
tended downwards into the sacrum. The laminae were imperfect at the seat of the 
tumour ; the central canal of the cord was dilated below the mid-dorsal region, and the 
left cornu of grey matter had disappeared, leaving a hollow space. This was evidently a 
combination of spina bifida, syringo-myelia, and a congenital tumour of cartilage and 
fat. The operation was undertaken with the view of possibly relieving the cord of pres- 
sure and so removing the paraplegia, but there is much risk of meningitis in these cases. 



As these growths are usually median in position or nearly so, they 
simulate spina bifida : hence they have been called ' false spina bifida ' (vide 
p. 528) ; they may have attachments within the spinal canal or pelvis. 

Any congenital tumour of the vault of the skull or over the spine should 
be looked upon with suspicion, as likely to have intimate relations with the 
cranial or spinal cavities. The appearance of the skin, the mobility of the 
tumour, its reducibility, and the effects of pressure, &c, are the points to be 
looked to {vide Chap. XXV.). It is sometimes impossible to diagnose 
nsevus from other soft growths ; the presence of 
cutaneous stains or of nasvi elsewhere, the effects of 
straining or crying, the possibility of partly emptying 
the tumour, and its peculiar spongy feel, must be taken 
into account {vide Chap. XVII.). 

Treatment. — Congenital lipomata, if large, rapidly 
growing, painful, or inconvenient, should be excised. 
The congenital sacral tumours, unless for some very 
good reason, should be left alone — there is much risk 
of injury to the spinal contents, as seen in the case 
just related. 

Cystic growths may be treated by tapping, injection, 
setons, incision, or excision ; none of these modes are 
free from danger, and the last is sometimes impossible 
from the extent and connections of the mass. In 
large unilocular deep-seated cysts, such as ' hydrocele 
of the neck,' tapping, followed by injection with 
Morton's solution if the cyst refills, is the best plan ; 
if suppuration occurs, free incision and drainage must 

be employed. The multilocular cysts are often best treated by setons, 
small threads being inserted and the process repeated if necessary. In the 
cavernous lymphatic naevi, much lymph may drain away if the growth is cut 
into, just as bleeding occurs from a blood naevus, and there is much risk 
of septic infection or exhaustion : hence these growths should be removed 
entire, if at all. 1 

In the case of giant foot the fatty variety has a tendency to steadily 
grow, and though pressure may slightly retard it, we have not found it suc- 
ceed as a means of treatment. Ligature of the anterior and posterior tibial 
arteries in the following case gave a good result for a time, but after a year 
or two the growth continued. In such cases the choice is between leaving 
the case alone and amputation ; the latter should only be done when the 




Fig. 179. — Section of Con- 
genital Sacral Tumour. 
a points to the spinal 
canal ; b to the body of a 
vertebra ; c to a mass of 
ossifying cartilage in the 
tumour. 



1 For further details vide T. Smith, Clin, Soc, Trans. 1SS0, vol. xiii.. and Birkett, 

Guy's Hospital Reports, i860. 



724 Tumour Growth in Childhood 

crippling from the presence of the growth is greater than would result from 
the mutilation. 

Case. — Pes Gigas. Lipoma* " :y. — Emily C, age 9 months; admitted June 23, 
1884. Family history unimportant. At birth it was noticed that the left foot was dis- 
tinctly larger than the right ; since that time it has steadily grown ; there has been no 
pain, and the child's health has been unaffected. "Thanks to the courtesy of Mr. Withers, 
of Sale, we were able to watch this case almost from the first." On admission, a fat, 
healthy child ; the left foot much enlarged, chiefly the dorsum and inner side ; toes not 
affected ; skin natural, dimples on raising it ; at the outer side a few hard nodules can be 
felt. Measurements : 



At root of toes 


6\ in. . 


. Ri 


ght foot 


4+ in. 


circumference. 


At middle of foot 


yh in. 




,, 


4t 


, , 


Across heel and foot 


8 in. 




,, 


= t 


,, 


Around ankle 


7 in. 




,, 


S* 


,, 


Middle of calf 


7 h in. . 




,, 


": 


,, 



Elastic pressure was fairly tried for a long time prior to admission without apparently 
diminishing the rate of overgrowth. The temperature of the two limbs did not appa- 
rently differ, and the child could kick the foot about, though unwieldily. On July 2 the 
posterior tibial artery was ligatured in the middle of the leg by the usual method, a 
catgut ligature being employed ; the vessel was very small, and its pulsations feeble ; a 
drainage tube was used; operation antiseptic; all went on well. On the nth the 
measurements were as before, except the one at the root of the toes, which was h in. 
less ; wound almost healed. July 12, the anterior tibial artery was ligatured doubly, and 
divided between the ligatures ; the veins were included in the ligatures. 21st, first 
dressing, wound all healed ; no drainage was used ; measurements as on nth, except 
middle of foot \ in. less. 28th, Martin's bandage applied'again ; the warmth of the foot 
seems in no way interfered with. August 4, measurements : — Root of toes, 6^ in. ; middle 
of foot, jh in. ; across heel and foot, 8 in. ; around ankle. j\ in. ; middle of calf, j\ in. 
February 1885, the foot is getting smaller in all dimensions. Subsequently the growth 
remained stationary for a while and then increased. 

Lymphoma lymphadenoma, lymphosarcoma; is sometimes met with 
in the shape of large masses of glands in the neck 'fig. 180) or elsewhere, 1 
which slowly grow and give trouble from their size, unsightliness, and pressure 
effects {Tide Hodgkin's Disease), as well as ultimately cause death. 

Removal of such masses of glands is usually of only temporary value ; it is 
seldom that all can be got away, and recurrence often takes place in a short 
time. Section of such a tumour shows a pinkish-grey lymphoid tissue with 
no caseous foci. 

The following was a characteristic case : — 

Case. — Lymphoma of Neck. — John T., age 12 years 4 months ; admitted November 
10, 1882. Family history good, except that the mother had abscesses beneath the jaw whilst 
pregnant with this child ; boy himself never very hearty, but had fair health ; four vears 
ago a swelling appeared beneath the lower jaw on the left side ; this grew slowly till the 
last three months — since then it has increased rapidly; for three weeks has had pain. 
On admission, in the left posterior triangle is a large globular tumour consisting of lobu- 
lated lymphomatous masses ; the swelling extends from 1 inch below the jaw to h inch 
below the clavicle, which it overhangs ; it is 5§ inches in transverse diameter ; some of it 
projects beneath the trapezius, and outlying masses reach nearly to the middle line of the 
neck ; the skin is movable over it, and it is not fixed to the vertebrae ; no marked glandu- 

1 Cystic lymphomata are sometimes met with, and these growths have been found in 
the rectum, among other places. 



Cystic Tumours of the Jaws 



725 



lar enlargement elsewhere, though a few slightly enlarged glands can be felt in the left 
groin ; some dulness over apex of left lung ; left pupil slightly smaller and less sensitive 
than right. On November 16 the gland masses were removed, weighing 8 oz. ; most of 
the glands shelled out easily, some were adherent ; the external jugular vein was tied and 
divided ; at times when traction was made upon the carotid sheath during the operation 
the pulse was much accelerated ; the carotid sheath and cervical transverse processes were 
exposed. He bore the operation well and lost little blood. Operation antiseptic, with 
sponge pressure ; recovery uninterrupted ; 
antiseptics were left off on December 6, and he 
was discharged with a small superficial wound. 
February 1883, the boy has been better since 
the operation, but new masses of glands are 
already beginning to enlarge, though at and 
after the operation none could be felt. 





Another case is shown in fig. 180. 
It is not at all uncommon to find cases 
in which certain of the glands have 
broken down and discharged, while in 
other respects the conditions resemble 
lymphoma rather than tuberculous. We 
have accounted for these cases by sup- 
posing that tuberculosis and Hodgkin's 
disease have coexisted. We have seen 
lymphoma also appear in a child the sub- 
ject of hip disease. Variation in the 
size of the swellings, associated with 
fever, but subsiding without suppuration, 
is also often seen. 

XVEultilocular Cystic Growths of the Jaws arise from epithelial 
ingrowths from the surface of the gum, which afterwards become shut off 
and develop cysts ; they may be congenital or occur in infancy. Besides 
these, two other forms of cyst are found associated with the teeth (dentary 
cysts) : (1) Cysts originating in connection with the tooth follicles — follicular, 
or, if they contain teeth, dentigerous cysts ; (2) Periosteal cysts, originating 
beneath the periosteum of the jaw. 

Dentigerous cysts arise from mal-placed or mal-developed teeth, and may 
occur at any part of the jaws ; they contain clear, serous or glairy, white or 
coloured fluid, rarely pus. Most often they are associated with the perma- 
nent, sometimes with the milk teeth. Eggshell crackling, the presence of 
fluid, and suppression of a tooth are the common indications of the nature of 
these swellings. (Eve, 'Brit. Med. Jour.,' Jan. 6, 1883; Heath, 'Lancet,' 
1887.) 

For further details on the question of tumours we must refer to the 
sreneral text-books. 



26 Diseases of the Thyroid and Thymus 



CHAPTER XXXIV 

DISEASES OF THE THYROID AND THYMUS 

Acute Enlargement of the Thyroid. — A slight enlargement with tender- 
ness of the thyroid gland is not uncommon, but any acute enlargement, the 
result of inflammation, is very rare. A typical case of this kind is recorded 
by Dr. T. Barlow, 1 in a boy of three years. The symptoms at first consisted 
in pain in the neck on movement, feverishness and slight enlargement of 
the thyroid gland. Later the swelling considerably increased ; the tempera- 
ture varied from ioo° to 103 F. ; there was some difficulty in swallowing, 
but no marked dyspnoea. In four or five days the swelling began to subside ; 
he finally made a good recovery. 

Chronic Enlargement. — Goitre. — Simple or cystic enlargement of the 
thyroid is sometimes met with in children, most commonly in the inhabitants 
of certain hilly districts such as Derbyshire ; it is however met with in 
cases among town-bred children, both with and without a family history of 
goitre. 

In the case here figured half the gland was removed ; it consisted of a 
mass about the size of a small orange ; in it were many cysts, the larger of 
which contained reddish-yellow fluid. The child did perfectly well, but died 
some months later of scarlet fever ; the other half of the gland had not 
appreciably altered after the operation. 

We have been three times called upon to perform tracheotomy in young 
people for urgent dyspnoea, the result of pressure of an enlarged thyroid 
gland ; in two cases the patients were young adults, the third was an ill- 
developed, idiotic child, in whom there was enlargement of the tonsils, with 
post-nasal vegetations ; these had been dealt with once with marked improve- 
ment, but on the second occasion sudden dyspnoea, evidently due to pressure 
of the enlarged thyroid, was brought on by any attempt at examination, and 
on administering chloroform the breathing stopped ; tracheotomy was per- 
formed, and the child did fairly well for a day or two, but died of bronchitis 
on the 3rd or 4th day. The operation under such circumstances may be of 
extreme difficulty alike from the presence of the large mass of gland, from 
the engorgement of the vessels, and from the altered shape of the trachea, 
which is compressed laterally. A specially long tube is required to reach 
down below the constricted part of the windpipe. There is no doubt that in 
any case where attacks of dyspnoea, ' thyroid asthma,' have recurred, either 
removal of part of the gland or division of the isthmus should be performed 

1 ' On a Case of Acute Enlargement of the Thyroid Gland in a Child,' by Dr. T. 
Barlow, Clin. Soc. Trans, vol. xxi. 



Thymus Gland 



727 






Fig. 181. — Cystic Bronchocele in a Child. 



in an interval between the attacks. 1 In simple cases of goitre the treatment 
is the same as for adults. 

We have divided the thyroid isthmus in a young gentleman of sixteen, in 
whom acute attacks of almost fatal dyspnoea had more than once occurred. 
The trachea was much flattened late- 
rally ('scabbard trachea'). Three weeks 
after operation the gland had resumed 
nearly its normal size. In another case 
the operation was done during an 
attack, and the patient died a few 
hours later from rapid oedema of the 
lungs. In another, part of the gland 
was removed and tracheotomy per- 
formed ; the patient recovered, though 
in cases where tracheotomy is neces- 
sary the danger to life is much in- 
creased. 

It is not very uncommon to see 
children in whom the thyroid is 
slightly enlarged and sometimes pain- 
ful and tender, but in whom there is no 
very great deformity and no cystic 
development. These cases of ' simple 
bronchocele ' may be met with at any 
age, but are perhaps most common 
about puberty. Under treatment with iodine or arsenic internally, and 
weak red iodide of mercury ointment, cautiously used, externally, the gland 
usually returns to its natural size. Iron is required if there is anaemia. 

The thyroid gland is usually absent in cases of myxcedema or ' sporadic 
cretinism ; ' in any case of wasting or disease of the thyroid the possibility 
of myxcedema must be borne in mind. 

Thymus gland. — The thymus body or gland reaches its greatest size at 
two years of age, after which it dwindles, and by puberty is in most cases 
reduced to a mere vestige. At birth it measures some 2 in. in length and 
perhaps 1 \ in. in breadth, and weighs about \ oz. At two years of age it weighs 
from i£ to 2 oz. It is situated behind the upper piece of the sternum, reaching 
as low down as the fourth costal space ; it lies partly on the pericardium, the 
aortic arch, and large vessels. 

But little can be said concerning the diseases of the thymus. Some 
authors have attributed laryngismus and spasm of the glottis to enlarge- 
ment of the thymus and a consequent pressure on the nerves or trachea 
itself. It is very doubtful if laryngismus is due in any way to hypertrophy of 
the thymus, but cases in which there was evident pressure on the trachea 
by an enlarged thymus have been recorded by Goodhart, Jacobi, ami 
Baginsky. Sudden death from spasm of the glottis is not uncommon during 
the first two or three years of lite, and this has in some cases been attributed 
to the presence of an enlarged thymus (Pott). We are by no means con- 
vinced of this. It is common to find small cysts at first sight looking like 
1 Vide Med. Ckron, vol. \i. 1800. 



728 Diseases of the Thyroid and Thymus 

abscesses scattered through the substance of the thymus ; these have been 
attributed to syphilis. Jacobi has noted an excessive quantity of connective 
tissue in the thymus of syphilitic children. He has also observed tubercu- 
losis of the thymus in cases of general tuberculosis. Demme has recorded 
a case in which caseous masses were found. The thymus when it becomes 
tubercular probably does so from contact with caseous mediastinal lymph 
glands, as in case related at p. 195. In some recorded instances it appears 
that sarcoma has originated in the thymus. 



729 



CHAPTER XXXV 

DISEASES OF THE SKIN 

DURING intra-uterme life the foetus is surrounded by the liquor amnii, and 
the skin is in consequence in a soft and sodden condition at birth. After 
birth it is subjected to the drying action of the air, it receives a larger blood 
supply than before birth, and the glands which it contains become function- 
ally active. It is now exposed to various forms of irritation, such as the 
contact of the urine, faeces, and various excretions, and the friction which 
takes place during washing. It is hardly surprising to find that under these 
new conditions the skin is often injured, especially when we bear in mind the 
delicate nature of the horny layer of the epidermis. In consequence of the 
rapid growth which is taking place, there is necessarily a continual building 
up of the tissues of the skin to keep pace with body-growth, and any inter- 
ference with the infant's digestion or assimilation of its food is exceedingly 
likely to interfere with the nutrition of the skin. This is seen in various 
conditions of wasting during infancy ; the skin becomes rough and harsh, or 
the slightest irritation from the urine or faeces, or friction at the flexures of 
the joints, gives rise to an erythema, eczema, or to excoriations. 

Reflex inflammations are more common during infancy than in later life, 
a transference of inflammation readily taking place from one part to another, 
or an irritation present in one place may give rise to an inflammatory lesion 
at a distance. In this way we find blotches or scaly spots about the mouth 
and face of children who are suffering from dyspepsia or gastric catarrh, or 
herpetic patches about the nose or mouth in those suffering from pneumonia 
or bronchial catarrh. Urticaria or erythematous blotches may be the result 
of indigestible food in the stomach, or the pressure of a tooth upon the gum, 
or the presence of acari burrowing beneath the skin. 

Lesions of the skin are exceedingly common during infancy and child- 
hood, and we find eczema, intertrigo, urticaria, and lichen among the most 
frequent ailments at this period. 

Eczema. 

Eczema during infancy, while often proving amenable to treatment, is 
exceedingly apt to relapse, and in aggravated cases it forms one of the most 
troublesome complaints with which the practitioner has to deal. Probably 
most can call to mind cases of eczema in infants a few months old which 
have improved for a while, then relapsed again and again, and for which 
numerous ointments, lotions, powders, and medicines have been tried in 
vain. While the majority o( these cases get well as the end o\ the first year 



730 Diseases of the Skin 

is approached, or only relapse occasionally, in many cases the eczema con- 
tinues to give trouble for years, or even for life. 

The causes of eczema in infants are various, and, indeed, but little is known 
for certain about many of them. In some cases, especially in the local 
eczemas, there are irritants at work, such as scabies, pediculi, and the fretting 
produced by napkins constantly wet with urine or fasces. There cannot be 
a doubt that there is a close relation between the condition of the skin and 
the alimentary canal. It is interesting to note that if a healthy infant gets 
an attack of dyspepsia or diarrhoea, its muscles become flabby, there is some 
wasting, and the nutrition of the skin is lowered ; and now the contact of 
urine or soiled napkins sets up an irritative erythema or eczema, the irritation 
of the soiled napkins being powerless to excite an excoriation, until the 
nutrition of the skin is interfered with by faulty assimilation. One of the 
commoner internal causes of eczema in infants and young children is a faulty 
condition of the alimentary canal ; probably, in some instances, the eczema 
is due to a mal-assimilation or insufficiency of food, and in consequence 
the nutrition of the skin suffers. Eczemas are usually worse during the cold 
east winds of spring. 

In what class of children is eczema the most common ? The answer 
must be that eczema may be found in children of every type and of every 
social grade. In the first place, it must be said that eczema is by no means 
uncommon in infants and children who are apparently in perfect health ; and 
breast-fed infants suffer as well as artificially fed infants. We have fre- 
quently noted in hospital that children admitted for some other disease, and 
who are quite free from any skin trouble, develop eczema as they become 
fat and well. In these cases there is a strong presumption that over-feeding 
may have something to do with the eczema ; it is certainly true that very 
fat children are often eczematous, and it is very possible that strong, healthy 
children with large appetites may habitually be overfed, and the system 
seek relief, as it were, in an acute or chronic discharge from the skin. 
Perhaps in some of these cases there is a history of eczema in the parents. 

On the other hand, as already remarked, dyspeptic children, and those 
who are badly or poorly fed, also suffer from eczema. 

The so-called strumous children are exceedingly likely to suffer from 
eczema, especially of the impetiginous type. The scalp, face, and backs of 
the ears are most likely to be affected : there is much oozing of a semi- 
purulent fluid, which dries and forms yellow crusts. The lymphatic glands 
are apt to become enlarged, and subcutaneous abscesses to form. 

It is a popular notion that much of the eczemas of infancy are due to 
teething, and that a chronic eczema is always worse when a tooth is being cut. 
Mothers often look forward to the last teeth being cut, as they believe that 
then the child will be free from eczema. In all this we think there is a great 
deal of exaggeration, but it is easy to understand that a swollen and tender 
gum may give rise to a good deal of crying, and some feverishness. And 
so any eczema, especially affecting the face, may be aggravated. 

Vaccination is frequently blamed by the parents of eczematous children : 
it is certain that a local eczema may arise at the seat of the vesicles, and 
an impetigo be started elsewhere in consequence of scratching ; but we do 
not think that vaccination gives rise to a general eczema. 



Eczema 731 

What part do micro-organisms play in producing eczema? It is quite 
certain that many cocci may be found in every eczema, but it hardly can be 
said that they are the cause of eczema in the same sense that the tubercle 
bacilli are the cause of lupus or phthisis. Given a papular itching eczema, 
then scratching removes the cuticle and inoculates the broken skin with 
cocci, which find a congenial soil in which to flourish. Much of the chronic 
inflammation which follows is doubtless the result of the growth of the cocci 
thus inoculated. Eczema may be self- inoculated, like true impetigo, by 
scratching. 

A tendency to eczema is hereditary. 

Symptoms and Course. — The commonest places for eczema in infants and 
young children (local irritants excluded) are the forehead, cheeks, scalp, and 
backs of the ears. The limbs, especially the flexures of the joints and backs 
of the hands, are often attacked. The usual form is eczema vesiculosum ; 
in weakly and scrofulous children the pustular variety, E. pustulosum or 
impetiginodes, is the most common. The former mostly begins with patches 
of redness, the inflamed patch quickly becoming the seat of numerous 
papules ; in less severe cases the papules may make their appearance in crops 
on apparently normal skin. In the worst cases the itching is intense, and 
the skin of the forehead or cheeks is hot, red, and cedematous. The papules 
quickly become vesicular and burst, or perhaps more often the inflamed skin 
begins to ooze without distinct vesicles being formed. A free discharge 
from the skin usually gives relief. The skin continues to weep, perhaps 
for some days, and probably also the eczematous patch is extending, cover- 
ing the whole forehead and affecting the cheeks, so that at this period all 
stages of the affection may be seen. In one place there may be redness 
only, in other places excoriated and weeping skin ; at another place the dis- 
charge has dried, forming crusts with raw, tender skin beneath ; where the 
eczema is nearly well the skin is thickened and the cutis desquamating. 
The skin of the thighs, flexures of the groin and knees, the arms and back, 
are very likely to become affected, and as the eczema heals in one place it 
is very likely to break out in another. Sooner or later the eczema passes 
into the subacute or chronic stage ; the skin is more or less red and indu- 
rated, there is less oozing from the surface, while there is a tendency to form 
crusts and for free desquamation to take place from the skin. This desquama- 
tion or scurfiness is particularly noticed on the scalp. 

In some cases the eczema is more of the erythematous type. The child 
goes to bed at night, and when warm in bed the face and forehead flush up, 
the skin becoming red, shiny, and hot ; the itching and tingling is intense, so 
that the child scratches and almost tears itself in its restlessness and dis- 
comfort, while sleep is out of the question. In the course of an hour or two 
the congested vessels are relieved by a serous discharge through the perhaps 
already damaged skin, and the inflammatory stage is succeeded by the 
oozing and crusting stage. The raw and tender skin left after the discharge 
more or less recovers and dries up, and then there is another inflammatory 
attack and the process is repeated. 

In weakly and scrofulous children the eczema is ol a less acute typo ; 
there is less redness, burning, and itching, ami a greater tendency to pus for- 
mation than when eczema occurs in strong and healthy children. Thescalp 



73 2 Diseases of the Skin 

and face are mostly affected : in these places much crusting takes place, the 
crusts being formed of dried pus, and on raising these more or less puriform 
fluid escapes. In the early stages pustules are usually present. In the 
worst cases the whole scalp is a mass of thick crusts, abscesses form in the 
scalp, glandular abscesses are present in the cervical glands, and perhaps 
' cold abscesses ' in various places throughout the body. In dispensary 
practice an eczema pustulosum of the back part of the scalp is almost 
certainly the result of pediculi. 

All forms of eczema in infants and young children are apt to relapse, 
fresh attacks coming on before the skin has entirely recovered from the 
effects of the last attack, and the old place is soon as bad as ever. The 
tendency is for the attacks to involve the same places time after time where 
the skin has been injured or has ' contracted a bad habit.' Often, however, 
while healing in one place it breaks out in another. The younger the infant, 
the more troublesome is the eczema ; the older it grows, the less likely is it 
to relapse. 

The eczemas, or perhaps more properly erythemas, caused by the con- 
tact of foul napkins, or by two surfaces of skin coming in contact (intertrigo), 
are exceedingly common in dispensary practice ; with ordinary care they 
never occur in healthy children, but in infants suffering from intestinal 
catarrh or diarrhoea, where the napkins are constantly soaked with the 
excretions, a certain amount of soreness may be difficult to avoid. The skin 
is usually first red, the erythematous eruptions spreading from the anus and 
genitals ; the horny layers of the skin become detached, leaving superficial 
excoriations, from which serum and perhaps blood may ooze. 

Eczema in older children does not differ from eczema in adults. Any 
part of the body may be affected — the face, trunk, or limbs, and especially 
the flexures of the joints. A subacute or chronic conjunctivitis is commonly 
associated with eczema of the face. The skin readily becomes red and in- 
filtrated, with a dry, rough surface, which readily cracks, making painful sores. 
The itching is usually severe, and the affected part is constantly fretted and 
irritated by the scratching which goes on. 

Children who suffer from eczema are usually constipated. 

Complications. — Children who suffer from eczema in some cases suffer 
also from bronchial asthma, in some cases the two diseases are co-existent, 
in other cases they alternate ; there is no constant rule as far as we have 
been able to determine. Eczematous children frequently also suffer from 
gastro-intestinal catarrh. This is only another way of saying that there are 
children who are specially prone to catarrh of the bronchial tubes, catarrh 
of the stomach and bowels, and also to a catarrhal inflammation of the 
external surface of the body. We have already remarked that eczema and 
impetigo may co-exist in the same subject, and so also may seborrhcea. 

Treatment. — The most scrupulous care must be taken to keep the healthy 
infant's skin clean, especially those parts which come in contact with the 
soiled napkins. A daily bath should be given from the first week, but a 
prolonged immersion must be avoided as likely to macerate and soften the 
cuticle too much. A good curd soap free from excess of alkali should be 
used, 1 and soft water in preference to hard. Some starch powder, such as 
1 Unna's ' over-fatty ' soap or ' Vinolia ' soap makes a good soap for infants. 



Treatment of Eczema 733 

finely ground rice or maize powder, with 20 per cent, of boracic acid, should 
be applied after careful drying. 

If the parts about the genitals become red or excoriated, attention must 
at once be directed to the state of the infant's digestive organs, to see if 
gastric and intestinal digestion is in a normal state, or if there is diarrhoea ; 
and it will probably be found that something is wrong here. The affected 
parts must be kept clean, as little friction as possible being used, and thin 
gruel, or rice boiled in milk, being used instead of soap ; or the parts may 
be cleansed with a piece of absorbent cotton-wool dipped in carron oil. 
(Lime water and linseed oil, equal parts.) After carefully drying, boracic 
acid powder, or oxide of zinc and starch (1-5), kaolin, or finely prepared 
fuller's earth, may be used to dust on. Where there is constant diarrhoea 
the ordinary napkin may be dispensed with, and pads made of absorbent 
cotton or wood-wool used instead, as they more readily absorb the faeces 
and urine. Unna's ' powder-bags ' are sometimes useful ; these consist in 
bags made of soft, fine muslin, and filled with some dusting powder, as zinc 
and starch, or Taylor's cimolite, and quilted, to prevent the powder from 
gravitating to one end. These bags may be made ready and used as re- 
quired ; their value consists in keeping the parts dusted by the powder, 
which escapes through the pores of the linen or muslin. 

The dietetic treatment of general eczema is often difficult, as it may be 
by no means clear that anything is wrong with the digestive organs. If the 
infant is being nursed at the breast, great care should be exercised by the 
mother as regards her diet : beer, tea, coffee, salt meats or greasy dishes, are 
best avoided, or taken only in moderate quantities, while milk, fish, fresh 
meat, and vegetables may be taken freely. The infant, if vigorous and full- 
blooded, is perhaps taking too much breast-milk, and the amount of milk 
taken should be lessened. Possibly the breast-milk taken may be poor 
in quality— containing an excess of sugar, while deficient in proteids and fat 
— the infant is flabby, poorly nourished, and suffers in consequence from 
impetigo or intertrigo ; in such cases some form of artificial food must be 
given in addition to the breast-milk. In artificially reared children the 
question of diet is of great importance.: eczematous infants being brought up 
on cow's milk are frequently constipated and pass large quantities of un- 
digested curd in their stools. In such cases Mellin's food, Benger's, or 
Savory and Moore's, may agree better than cow's milk and water. In older 
children, especially if there is an excess of fat, starchy and saccharine foods 
should be avoided, and the diet confined as much as possible to milk, cream, 
eggs, broth, underdone minced meat, and green vegetables. 

The medicinal treatment must be directed to overcoming the constipation 
so often present, and exciting the action of the liver ; small doses of mercury 
euonymin, or rhubarb and soda may be prescribed. (F. 30 or 31. 

Small doses of Rubinat or Hunyadi water are often successful. 

Of other internal remedies in the acute stages, alkalis, such as the citrate 
or bicarbonate of potass, with nux vomica, are frequently useful. Effervescing 
citrate of potash and lithia is useful, both in acting on the bowels and 
kidneys. Carlsbad salts, taken before breakfast in warm water several times 
a week, may he prescribed in older children. Arsenic is rarely, it" e\ er. o{ use 
in the early stages of infantile eczema : indeed, we have seen cases which 



734 Diseases of tJie Skin 

were made distinctly worse by it. In older children in the chronic stages, 
where there is a disposition to excessive desquamation, it is usually beneficial. 
In the chronic impetiginous eczemas of scrofulous children cod-liver oil and 
the iodides may be prescribed with great advantage. Cod-liver oil and 
arsenic may be given, or arsenic can be added to some ready-made cod-liver 
oil emulsion. (F. 32.) 

In the management of local remedies much depends upon how the 
application is used, and much time and trouble may be well bestowed in 
showing the friends of patients how to apply the dressings, and, what is by 
no means easy, to keep them in position. Merely smearing on an ointment 
or dabbing on a lotion may be an entirely valueless proceeding ; moreover, 
the newly formed cutis is very easily injured. The ointment or lotion re- 
quires to be kept in constant contact with the part if it is to be of much use. 
In infants and young children some method will have to be adopted to 
prevent scratching ; mittens must be placed on the hands, and in some cases 
it may be necessary to secure the arms by means of bandages. 

For application locally the range of remedies is very wide, and various 
combinations have been called into requisition in the way of lotions, 
liniments, and ointments. As a rule, in all acute eczemas, where there is 
much excoriation of the skin, or thin, newly formed skin present, much 
washing or rough handling should be avoided. On the other hand, in 
chronic cases, where the skin is thick, scaly, or infiltrated, baths are of great 
service in removing the scales and softening the skin. In all eczemas, how- 
ever, a certain amount of cleansing is necessary to remove the remains of 
the old ointments and crusts : this can usually be done by gently applying 
some almond oil — or carron oil answers very well — ordinary soap being best 
avoided in acute cases. 

In all acute or subacute eczemas soothing remedies are required, and 
must be persevered in as long as there is an irritable condition of the skin 
and free discharge. The most troublesome eczemas in infancy are those of 
the face. In these, when the skin flushes up and is hot and angry during 
the evening exacerbation, and the infant sleepless and restless from the 
burning and itching of the skin, hot poppy-head or opium fomentations often 
give relief. Perhaps more often cooling applications are the most grateful ; 
these ma)' consist of carron oil with 2 per cent, of ichthyol or calamine lini- 
ment. (F. 33, 34, 35.) 

Any of these lotions may be carefully dabbed on and allowed to dry, to be 
followed by a soothing ointment, or pieces of lint may be soaked in the 
liniment and kept continuously applied by means of a gauze bandage. The 
ointments most suitable for the face in acute or subacute conditions are 
those whose basis consists of cold cream or the ung. aquae rosas of the 
United States ' Pharmacopoeia,' such as F. 36. This ointment must bespread 
on lint and kept continuously applied, being changed twice a day and reapplied. 
When the eczema has passed into the scaly stage, and there is no large 
amount of discharge from the skin, more stimulating ointments may be used 
and the face kept continuously bound up to exclude the air. There should be 
a daily cleansing with carron oil to remove the excess of ointment and the 
accumulated scabs, and zinc ointment (F. yj) may be applied on lint. 
Lassar's and Ihle's pastes are useful, and form a protective covering to the 



Treatment of Eczema 735 

newly formed skin, but they are difficult to remove if allowed to cake on 
to any extent. (F. 38, 39.) 

In impetigo, where the discharge is more or less purulent and much 
scabbing takes place, the scabs should be removed by poultices or the appli- 
cation of carbolic oil, and some diluted mercurial ointment applied (F. 40, 
41)— or an ointment consisting of five orten grs. of iodoform in simple oint- 
ment may be used. 

Eczema affecting the scalp must be treated in a similar manner to that of 
the face, except that, as a rule, more stimulating applications may be applied. 
In the weeping and irritable stage carron oil or the calamine liniment 
(F. 33) or zinc and cold cream may be applied on lint or rags, and a nightcap 
worn by the child to protect the parts and prevent the infant from scratching. 
The hair must be kept short and the scalp cleansed every morning with some 
mild soap and warm water ; or thin gruel may be used. In the more chronic 
stages, especially in neglected cases, the crusts must be removed by oiling 
and poulticing, and some diluted white precipitate ointment or other mild 
mercurial ointment applied. Lassar's or Ihle's paste (F. 38, 39; may be 
used, being put on thickly, thus dispensing with any lint ; the crusts and 
excess of ointment must be removed daily or every few days. Eczema of 
the scalp, the result of pediculi, should be treated by poulticing, cutting the 
hair, and the continuous application of white precipitate ointment. 

In the chronic general eczemas of older children, especially where the 
skin is rough and coarse, and there is much infiltration, and the flexures of 
the joints are affected, baths and stimulating liniments, followed by some 
soothing protective ointment, usually answer best. Soft soap, the pure 
green variety, may be rubbed over the parts on a wetted flannel for a minute 
or two so as to soften the skin ; it is then washed off in a warm bath, the 
child dried, and some strips of lint coated with zinc and lead ointment 
applied. This plan answers well in hospital, but the application of the soft 
soap causes smarting, and in private practice the child's friends are apt to 
think it makes the eczema worse and fail to persevere. Instead of the soft 
soap the parts may be sponged with lead and carbolic lotion (F. 42) every 
evening for a few minutes, the old ointment having been cleaned off, to be 
followed by simple zinc or lead ointment. 

In acute general eczema, where large surfaces of the body are affected, 
liniments applied on rag or lint should be used, and the parts firmly bandaged 
with gauze bandages so that the application may be kept in constant contact 
with the skin. When there is much discharge and the skin inflamed and 
tender, it is sometimes best simply to powder on some finely ground boracic 
acid and surround the limb with absorbent wool, firmly bandaged on ; or 
strips of lint may be saturated with carron oil ; calamine liniment (F. 33) or 
glycerinum plumb, subacet. (1 -10) may be used. In a later stage, when the 
skin is thickened and scaly, with but little or no discharge, more stimulating 
applications are necessary; ointments containing mercury, tar, zinc, or lead 
are usually prescribed (41, 43). The ointment should be of tolerably linn con- 
sistence, so as not to melt too readily and run into the lint. 

For general eczemas Pick and Unna have employed glycerine jelly 
medicated with zinc and other ingredients, painted over the skin after 
melting into a liquid. The glycerine jelly is dispensed in a tin or jar, which 



y 36 Diseases of the Skin 

can be stood in hot water till liquefied, and it is then applied to the skin by 
means of a brush. The parts are then covered by a thin layer of absorbent 
wool ; large surfaces of skin can be covered in this way. This application is 
unsuitable if there is much discharge from the skin, as the oozing quickly 
dissolves away the gelatine. We have found in cases in. which we have 
used these applications that the surface of the application, unless well 
covered with cotton wool, adheres to the clothes of the patient, and is easily 
detached. Unna's formulae are F. 44, 45. 

When large surfaces are involved, as face and trunk and limbs, we prefer to 
use carron oil as a dressing or to powder with boric acid, in preference to 
covering large areas with gelatine paints. 

In local eczemas, especially those about the nose, back of the ears, and 
flexures of the joints, Unna's salve plaisters or salve muslins are very con- 
venient and efficacious. Pieces of these can be cut with the scissors to any 
shape, and when placed over the patch of eczema can be readily held in 
position by a light bandage. The zinc and red oxide of mercury salve 
muslin and tar and lead are the most useful. 

The older writers generally uttered a note of warning against too rapidly 
curing a chronic or a general eczema, implying there was danger in ' driving 
it in.' This is ridiculed by those modern writers who look upon eczema as a 
local parasitic disease to be cured entirely by local parasiticide remedies. 
Now we think there may be a risk in the case of a full-blooded, overfed in- 
fant or child, if the discharge from a more or less general eczema suddenly 
ceases, and such eczemas are apt to heal in one place and rapidly break out 
in another. We have twice seen a high temperature, convulsions, and death 
take place in fat infants who were admitted to hospital for a general eczema, 
and who were treated with zinc-glycerine jelly, painted over a large surface. 
Whether in these cases it was post hoc or propter hoc we were unable to say. 

Impetigo contagiosa. — This eruption is characterised by the formation 
of crops of vesicles of various sizes, which become converted into pustules. 
The pustules dry up or become ruptured, leaving a greenish-yellow thick 
scab. The eruption is most common about the face, especially round the 
mouth ; it may also occur about the neck and hands. In some cases there 
is marked febrile disturbance before the vesicles appear. When the patient 
is seen for the first time, after having been affected for several days or a 
week, but few vesicles may be present, and only scabs and crusts visible on 
the face and back of the neck. The disease, as its name implies, is con- 
tagious, being transferred by means of the nails from one part of the body 
to another, and from one child to another in a similar way. The attacks 
may be acute in character, and the constitutional disturbance severe. It 
occurs in cachectic children and is rarely seen except in hospital practice. 
There is a close resemblance between impetigo contagiosa and some forms 
of eczema. Indeed we should say clinically there is no sharp line of 
demarcation between them. The treatment consists in removing the scabs 
by oiling or poulticing, and applying dilute white precipitate ointment on lint. 
Cod-liver oil should be given internally. 

Occasionally another form of pustular eruption is seen in children, which 
differs from the ordinary impetigo contagiosa in that it is far more inveterate 
and gives rise to ulcers beneath the crusts which form. Duhring has called 



Erythema 737 

attention to such a form which he describes ' as distinguished from I. contagiosa 
by its not being contagious, by its being a pustule from the first, formed 
deeper in the cutis, and rounded instead of flat.' (Duhring, quoted by Crocker.; 
We have seen cases which answer more or less to this description, but they 
have certainly been auto-contagious, and so presumably may be spoken of as 
contagious. In one of our cases, a boy of three years, the rash when 
first seen suggested small-pox. He was covered with pustules more or 
less flattened, and apparently loculated, on the face, scalp, trunk, and extremi- 
ties. The pustules were surrounded by a red zone, and in places the pus- 
tules had been converted into thick scabs, under which there was deep ulcera- 
tion. There was history of measles a month before. He was admitted to 
hospital, but in spite of treatment fresh pustules formed. These pustules 
were due to inoculation ; they gradually dried up, leaving large round scabs, in 
some cases an inch in diameter, and surrounded by a red areola. It was 
necessary several times to scrape the scabs and soft material away from the 
ulcers beneath the scabs under an anaesthetic. He was in hospital for three 
months, and sent out well, but with large scars. We have seen several 
similar though milder cases. The child was an epileptic, and the rash ap- 
peared to be worse when taking bromide. Was it a bromide rash ? In the other 
cases resembling this coming under our notice no bromide had been taken. 
Seborrhoea. — Seborrhceais a ' functional disorder of the sebaceous glands, 
producing increase of the secretion, which forms an oily, waxy, or scaly 
accumulation on the surface.' (Crocker.) 

The most familiar example of this disorder is seen in dispensary practice 
in infants who are badly looked after and rarely washed ; in such there is often 
an accumulation of a dirty yellow material over the anterior fontanelle, which 
can be scraped off with a blunt instrument. A certain amount of eczema 
may be present. What has been termed dry seborrhoea is not uncommon 
in the scalp of older children ; it may occur also on the face as well as on 
the trunk and limbs ; the scalp is dry and covered with small scales or scurf, 
which fly out when the head is combed or brushed. Care must be taken 
not to mistake diffused ringworm of the scalp for simple seborrhoea. 

Treatment. — The excessive sebaceous secretion on the scalp of infants 
can usually be removed by gentle friction with a piece of flannel dipped in 
warm olive or almond oil, following this up with washing with soap and 
water ; this process may want repeating once or twice, and care must be 
taken to keep the child's head well washed. If there is a tendency to exces- 
sive secretion, a little ung. hydrarg. ox. flav. (5 per cent, in vaseline) or ung. 
boracis (5ss ad 3J benzoated lard) should be applied. For dry scaly patches 
on the face an ointment consisting of precipitated sulphur in cold cream (5ss 
ad 5J) may be used. 

Erythematous Eruptions. — The term ' erythema ' is applied to those 
eruptions which consist in a redness or congestion of a more or less extended 
portion of skin, as well as to other eruptions, where there is not only a con- 
gestion, but an actual exudation from the cutaneous vessels, as in erythema 
nodosum. 

A simple erythema or congested portion of skin occurs under various 
conditions : it may be the result of some external irritation, Mich as the con- 
tact of fouled napkins ; the application of various irritants, such as mustard. 

3 r> 



738 Diseases of the Skin 

chrysarobin, arsenic ; or the bites of insects. An erythema sometimes pre- 
cedes the eruptions of the specific fevers : this occurs at times in small-pox, 
chicken-pox, vaccinia ; and it accompanies other febrile disorders, which are 
not usually accompanied by a rash, as diphtheria, cholera, and septicaemia. 
An erythematous redness is often present when there is a high temperature, 
as in pneumonia and other febrile disorders. An idiopatic erythema 
or roseola is not uncommon in . infants and young children, mostly as 
the result of some intestinal irritation, possibly also due to the irritation of 
the gum caused by dentition. It is more or less patchy in its distribution, 
occurring on the forehead, face, trunk, or limbs ; there may be no marked 
constitutional disturbance, and the patches of redness may be the first 
symptom. In other cases there may be several degrees of fever, restless- 
ness, and perhaps vomiting. The eruption is mostly fugitive, disappear- 
ing in a few hours to 24 hours. Other patches may appear as the first ones 
fade. 

Erythema Scarlatiniforme. — Is a typical 'scarlet fever rash ; ever 
present in any non-scarlatinal case ? It is difficult to answer this question 
dogmatically, but it may certainly be said that in any case when there is a 
diffuse, well-marked, punctiform rash, remaining visible for at least 24 hours, 
the disease is almost certainly scarlet fever or rubella. It is certain, how- 
ever, some erythematous or roseolous rashes do closely resemble scarlet 
fever, and, as they are attended not infrequently with some constitutional 
disturbance and fever, the difficulty in diagnosis may be very great. 

Some children are especially liable to roseolous rashes resembling scarlet 
fever, as the result of indigestion or some other source of irritation : a roseo- 
lous rash is also apt to occur in septic conditions, such as in an empyema, or 
wherever pus is shut up in a cavity. 

The constitutional disturbance in these cases is generally slight : the 
temperature may reach 101 or 102° F., the tongue may be slightly coated, 
but the child feels usually quite well, and his appetite is normal. The rash 
may very closely resemble mild scarlet fever : it is, however, as far as our 
experience goes, never so intense as it is in a typical or well-marked case of 
scarlet fever : moreover, in some part of the body it is almost sure to be 
patchy and unlike scarlet fever. The distinction between the roseolous and a 
scarlet fever rash may be difficult or impossible if one part of the body only 
happens to be seen, but the difficulty usually disappears if a careful examina- 
tion of the whole body be made, as in some places, especially the face and 
trunk, the roseola is patchy, the patches having a sharp outline. Crocker 
speaks of a roseolous rash lasting two to six days, and followed by a more or 
less copious desquamation. We have never seen such a case, and should be 
extremely suspicious of scarlet fever in such cases. In our experience an 
erythematous or roseolous rash, while it may closely resemble a scarlet fever 
eruption, is more fugitive, and rarely lasts more than twenty-four or forty- 
eight hours, and is not followed by desquamation. In the majority of cases 
the presence or absence of a tonsillitis will decide the diagnosis. 

A roseolous rash may follow the taking of certain drugs, more especially 
belladonna, copaiba, and salicylic acid. 

Erythema Pernio. Chilblains. — Children with slow circulations, espe- 
cially the so-called strumous, are very apt to suffer from chilblains. The favour- 



Urticaria 739 

ite spots are the toes, heel, and fingers ; they begin with redness and intense 
itching, or aching, coming on towards evening, or when the patient is warm. 
The skin is smooth, livid, and shiny, and ulceration may take place if it 
is subjected to much friction. Children subject to chilblains should wear 
warm woollen stockings and well-fitting boots with broad toes and thick 
soles, and should take much exercise. In the early stages the affected parts 
may be painted with equal parts of tr. iodi and lin. aconiti, orlin. saponis co. 
with an equal quantity of lin. belladonnas. A mild capsicum ointment also 
answers well (capsici 5 SS ; almond oil 5ij> lanoline 5 v j)> rubbed in with a 
piece of flannel. Zinc ointment with ung. hydrarg. ox. rubri, or ung. picis liq., 
in varying proportion according to the stimulating effect desired, may be 
applied. 

Erythema Multiforme is mostly seen during early life in association 
with rheumatism, or in rheumatic subjects ; whatever importance it possesses 
is derived from this association. The outbreak of this form of erythema is 
always suggestive of the rheumatic state, and an examination of the heart 
for endocarditis should always be made. The most common form consists 
in red papules surrounded by more or less congested skin. In association 
with the papules there may be flat raised patches surrounded by a zone of 
redness (erythema marginatum). Sometimes the eruption becomes purpuric, 
and bullae or vesicles may form. 

Erythema Nodosum has apparently a close relationship to the erythema 
just described, though the constitutional disturbance is often much greater. 
Prior to the appearance of the nodes there may be rheumatic pains and fever, 
the temperature perhaps reaching 103 or 104 , and the child is apparently 
quite ill (see fig. 37). The eruption appears most copiously over the shins, 
but the arms, especially on the extensor surfaces, or any part of the body, may 
be attacked : it appears as node-like, tender, red swellings of various sizes, 
accompanied by a burning or itching sensation. The patches come out two 
or three at a time in various parts of the body. At first rose-red in 
colour, they then assume a darker-red colour, and as they disappear become 
of a yellow colour like a fading bruise. 

Not much treatment is required for. erythema multiforme or nodosum. 
A light milk diet, a mild aperient with some saline, with salicylate of soda if 
rheumatism, is suspected. Locally, lead lotion with some tr. opii or liq. car- 
bonis detergens may be used. 

Urticaria is characterised by the sudden appearance of elevated blotches 
or wheals, at first red in colour, afterwards becoming white and sur- 
rounded by a zone of redness. They are attended by much burning and 
itching. The blotches usually disappear in the course of a few hours, but 
most frequently there are successive crops. In some cases a certain 
amount of ccdema is produced by urticaria ; we have seen children with 
oedema of the eyes and backs of the hands following nettle-rash. There is 
usually some gastro-intestinal disturbance. Urticaria is sometimes, espe- 
cially in infants, a distressing and troublesome complaint, the intense itching 
making the child restless, and entirely preventing sleep. Urticaria is the 
result, in the large majority of instances, of some irritation in the alimentary 
canal, less often upon teething ; sometimes it is due to the bites of insects 
or scabies. Worms are not an uncommon cause in young children : fruits 



740 Diseases of the Skin 

of various kinds, especially strawberries, fish, sausages, stale meat, sour 
milk, or any kind of fruit which disagrees, may act as a cause. 

The most troublesome form of urticaria is that variety known as urticaria 
papulosa or lichen urticatus. This is a very intractable affection and 
may last for many months or even years. When seen in dispensary practice 
it is very apt to be mistaken for scabies, as the rash consists of numerous 
papules ; many are often scabbed over as the result of scratchings about the 
body, limbs, hands, and feet. In the worst cases the whole body is covered 
with itching papules, in some places, perhaps, becoming pustular, making 
the resemblance to scabies a very close one, but no ' burrows ' can be dis- 
covered. The eruption begins as small wheals, which become papules, 
fresh ones coming out every night in crops when the child goes to bed. Its 
rest is broken, and its health may be seriously interfered with. It is most 
common during the period of the first dentition, and the tendency to it 
mostly disappears at three or four years of age. In the milder cases there 
is a succession of papules, some of which are surmounted by a small vesicle, 
which is quickly broken by scratching. After two or three days the rash 
ceases to make its appearance, to return, perhaps, in a few weeks. Gene- 
rally speaking, urticaria is more common in summer than winter. 

In some children fleas and other insects will produce vesicles as well as 
papules, and give rise to more or less constitutional disturbance. 

Treatment. — An aperient should be given, calomel or rhubarb and soda 
being the best. Santonin and calomel may be given if worms are suspected. 
A saline such as citrate of potash or bromide of potassium may be ordered. 
Locally, sponging the wheals with lead and tar lotion (such as F. 42) is 
perhaps the best application, or each wheal may be rubbed with menthol or 
painted with collodion. Sulphur baths (sulphuret of potassium, §ij to a bath) 
are useful in the chronic varieties. 

lichen Scrofulosus ' is characterised by very small inflammatory papules 
of a red colour, fading to that of the normal skin, disposed in groups or circles, 
and occurring mainly in scrofulous subjects.' (Crocker.) 

This form of lichen is not common in our experience, but it is easily 
overlooked, inasmuch as it is unattended wtth any great inconvenience to the 
patients ; they may make no complaint, and it is only discovered accidentally. 
The important points in the diagnosis consist in the absence of irritation 
and the presence of caseous lymph glands or other well-marked evidence of 
scrofula. The papules are small, and of a bright red colour at first, gradually 
changing to dull red, desquamating, and finally leaving a brown stain. 
They may be present on the trunk or limbs. Their course is very chronic, 
fresh papules appearing as the old ones fade, so that the patient may not be 
entirely free for months or years. 

Psoriasis. — This affection is common in children over three years of 
age, but is seldom so severe or so intractable as it often is in adults. It is 
perhaps even more liable to recur in children than in adults. The symptoms 
are so similar during chilhood to those seen in after-life that no detailed 
description is necessary. The treatment we usually adopt is to give arsenic, 
beginning with two-minim doses and gradually increasing it. Warm baths, 
with the moderate use of green soft soap to remove the scales, applying 
some tarry or mercurial ointment. In hospital patients we have used 



Dermatitis Gangrenosa Infantum 741 

Auspitz's solution of chrysarobin with great success. The solution is applied 
to the spots twice a week, the patient wearing old linen to avoid damage. 
(F. 46, 47.) 

Pityriasis Rubra. — We have occasionally seen this disease in children, 
but it is comparatively rare. The best marked case we have seen was in a 
girl of eight years ; twice over she has been in hospital with a precisely 
similar attack. The rash appeared to commence on the chest, and spread 
over the arms, trunk, and extremities. It consisted of a red rash covered 
with fine thin scales. Both attacks proved very chronic. A lotion of 
bichloride (1-5000) was used, but had to be stopped on account of salivation. 

Miliaria. Sudamina. — In various fevers, such as scarlet fever, enteric, 
and in other febrile disorders, as rheumatism, a number of minute vesicles 
with clear contents make their appearance on the skin. The clear fluid is 
sweat, which has been unable to escape from the orifice of the sweat gland ; 
the contents of the vesicles are absorbed or dry up in a day or two, leaving 
a tiny desquamating spot. In other cases a slight inflammation occurs at 
the blocked sweat gland, and a minute papule appears instead of the vesicle, 
though vesicles may also be present ; this condition has been called Miliaria 
rubra. The so-called Xiichen strophulus or ' red gum ' is, according to 
Crocker, a sweat rash ; it consists of minute crops of red papules which 
make their appearance in infants ; they are attended often with much itch- 
ing and consequent restlessness of the infant. A somewhat similar rash has 
been attributed to dentition as well as to gastric irritation. The papules 
should be dabbed with the lotion F. 35 or F. 42, and powdered with boracic 
acid or some drying dusting powder. 

Pemphigus is rare in infants apart from syphilis, but attacks of the 
acuter form of the disease {Pemphigus neonatorum)^ occurring in epidemics 
in lying-in hospitals or in the practice of a midwife, have been recorded by 
continental writers. In these cases the disease appears to have been dis- 
tinctly contagious : not only has it apparently passed from infant to infant, 
but also from infant to nurse. In a few cases the eruption is preceded by 
fever, restlessness, or convulsions ; the rash usually appears at the end of 
the first week. The bullae vary in size ; their contents are clean or slightly 
cloudy, rarely pustular ; they gradually dry up, forming superficial ulcers or 
crusts. All parts of the body may be attacked, and, unlike syphilitic pem- 
phigus, there is no preference for the palms of the hands or soles of the feet. 

Chronic pemphigus is seen occasionally in older children ; in some of 
these cases the children appear to be in good health and complain of nothing 
except the eruption, for which no cause can be assigned. In most cases 
there is marked anaemia, and more or less fever and constitutional dis- 
turbance ; the latter may be severe. The number of bullae varies from two 
or three to perhaps twenty ; they appear as vesicles on the face, trunk, and 
limbs, gradually enlarging, and finally drying up in the course of a few days. 
The treatment consists in giving arsenic in full doses, and cod-liver oil 
Locally, boracic acid or zinc ointment may be applied. In the severer oases 
continuous baths arc useful. 

Dermatitis Cangrgenosa Infantum. — In speaking oi varicella we have 
referred to a peculiar form of multiple gangrene of the skin, which is apt to 
follow varicella in anaemic or emaciated children (pp. 291, 292). Thei 



742 Diseases of the Skin 

reason to believe that this condition is not necessarily preceded by varicella, 
but may follow other pustular eruptions (Crocker) ; it has been known also 
to follow vaccination. It almost always occurs in infants or young children 
under three years of age, and in many of the fatal cases tuberculosis has been 
found. In these cases the varicella vesicle or pustule is succeeded by an 
ulcer, which rapidly extends in size and depth, frequently several joining 
together, so as to form large sinuous ulcers ; the floor becomes black from 
the formation of sloughs. In the worst cases the scalp, face, body, and limbs 
are covered with sloughy-looking ulcers, either separate or having joined 
together. There may be marked constitutional symptoms. In one of our 
cases there was recovery, the ulcers gradually healing up ; in the majority 
of cases a fatal result ensues. The treatment consists in giving the child 
a generous diet, including beef tea and wine, and dressing the ulcers with 
iodoform or other antiseptic ointment. 

Drug- Eruptions. — The most important rash belonging to this class is the 
Bromide eruption. In some children a few grains of a bromide salt are 
sufficient to cause a rash, while in other cases the salt may be taken for 
weeks or months together without giving rise to any eruption. Infants 
perhaps are more liable than older children. The rash consists in most 
cases of a red papular rash, the papules being discrete and chiefly occurring 
on the face, scalp, trunk, and limbs. On the summit of the red papules are 
one or more yellowish points, or small pustules. The rash looks more like 
acne than any other rash. It is sometimes confluent. Scabbing and ulcera- 
tion may take place (see p. 737). 

A somewhat similar rash also occurs after taking Iodides, but it is less 
common. Antipyrin and Phenacetin in some recorded cases have given rise 
to a ' measly ' eruption or an urticaria. We have several times noted a papular 
rash after giving antipyrin. The long administration of Arsenic is some- 
times followed by a darkening of the skin, especially marked on the abdomen 
and trunk. The pigmentation disappears after the drug is left off. 

Salicylic acid or the soda salt sometimes gives rise to a 'measly' or 
urticarial rash. 

Tinea. Tonsurans. — Ringworm of the scalp is one of the most trouble- 
some local diseases with which the practitioner has to deal, and one which 
is apt to bring unmerited discredit on account of the many months or even 
years that the disease sometimes lasts. In some children there seems to be 
an especial disposition of the disease to spread, and to relapse when to all 
appearance it has been cured, or, in spite of the local treatment vigorously 
carried out for months, no marked improvement ensues and everyone con- 
cerned becomes tired of the case. 

Ringworm is exceedingly contagious, one child taking it from another in 
consequence of the spores of the tricophyton being transferred from one to 
another by direct contact, or by means of hair-brushes, combs, caps, or bed- 
linen being used both by the affected and the healthy. It rarely affects 
infants, or children after puberty, its subjects, especially in the chronic form, 
being the weakly rather than the strong, though exceptions may be met 
with. 

The disease when recent may be recognised at a glance : the patches are 
circular, the central skin in the smaller ones being red in colour, while at 



Tinea Circinata 743 

the circumference desquamation is freely going on, the branny scurf giving 
the patch at this part a greyish or yellowish appearance ; the hairs from the 
central part may have come away, or they have broken off, leaving stumps. 
In the larger patches all traces of redness have disappeared, and they are 
simply bald or scurfy patches of varying size. Chronic diffuse ringworm of 
the scalp, especially if it has undergone a certain amount of irritation as the 
result of treatment, is more difficult to diagnose ; there may be much scurfi- 
ness, perhaps scabbing and pustulation. In the condition known as kerion 
the hair follicles suppurate, the hairs becoming loosened at their roots, and 
there is redness and puffiness of the patch. The diagnosis of ringworm is 
made from the stumps of hair left after the hair has broken off. These are 
best seen by means of a lens of two or three inches focal length : the stumps 
will then be readily seen often more or less twisted or bent, and having lost 
the gloss ordinarily seen on the hair. They are readily extracted with for- 
ceps, as they are mostly loose in their follicles ; they can then be placed upon 
a glass slide with a drop of liq. potassas and examined after soaking for half 
an hour. The broken hair will be seen to be frayed out at the end, and 
moreover infiltrated with conidia or spores ; the latter are readily seen with 
a power of 300 diameters if a sufficient time has been allowed for the caustic 
alkali to dissolve the fatty matters and render the hair transparent. The 
mycelium is less readily seen than the spores. It is needless to say it is 
mostly useless to examine the unbroken hairs, and in old cases which have 
been treated no spores may be present in the scurf. The greatest caution 
must be exercised before pronouncing that a case is well, or certifying that 
it is no longer infectious, as cases relapse again and again, and may be 
the means of communicating the disease to others. Before any case can be 
said to be cured, repeated examinations must be made with the aid of a lens 
for diseased hairs, any suspicious-looking stump being extracted and 
examined microscopically ; it is well to remember also that scurfy patches, 
even when the hair is growing freely over them, are extremely suspicious. 
In every case some mild parasiticide should be continued to be applied for 
some time after the disease appears to have been eradicated. In seborrhcea 
or non-parasitic scurfiness the whole scalp is affected, and, though the hair 
may come out, there are no broken stumps and no sharply defined patches 
of scurfiness as in ringworm. 

The course of ringworm is apt to be exceedingly chronic, and when 
undertaking the treatment of a case it is well not to be too ready to name a 
definite time when it will be well. 

Tinea Circinata. — Ringworm of the body is frequently associated with 
ringworm of the scalp. It is first seen as a raised red spot, which becomes 
scaly at the periphery as it enlarges, while the centre may present more 
or less healthy skin ; as the ring enlarges it becomes more or less broken 
and fainter. It may be present on all parts of the body ; it is perhaps 
commonest on the face and neck. The diagnosis is generally easy, though 
sometimes the patches of scurfiness on children's faces may be mistaken for 
ringworm, but do not assume the formation of a ring with a normal skin in 
the centre ; if any difficulty occurs, an examination of the scales scraped off 
the patch for spores would decide. 

Treatment.— -The treatment of tinea circinata is a comparatively simple 



744 Diseases of the Skin 

affair, and is readily effected by the continuous application of some mercurial 
ointment or solution for a few days or a week. It is well to commence 
treatment by removing the scales as far as possible with soap and water, and 
then some dilute white precipitate ointment may be gently rubbed into the 
patch morning and evening. An ointment containing sulphur, 5ss, and ung. 
picis liq., 5j 5 to the ounce of benzoated lard also answers well. Carbolic oil 
or carbolic acid in glycerine (1-8) may be used. 

In the treatment of ringworm of the scalp the first step to be taken is to 
cut the whole hair off with a pair of scissors to at least half an inch, leaving 
a fringe if thought desirable ; the scalp can then be carefully examined, and 
it will be usually found that there is more extensive disease than was at first 
thought. Wherever there are any patches of ringworm the hair must be 
cut close to the scalp both over and aroimd the patch. The scalp should be 
thoroughly washed with soft soap or carbolic soap, removing all or as many 
of the scales as possible. The ointment or application selected should then 
be rubbed in by means of a mop of rag for a few minutes, at least twice a 
day. Very many parasiticides have been recommended ; the one we have 
mostly used, and which is certainly as successful as any, is the oleate of 
mercury, and we fully endorse Dr. Alder Smith's praises of it. An oint- 
ment containing 5 per cent, is used for children under eight years of age, and 
10 per cent, for older children ; a small piece of the ointment is rubbed 
vigorously into the affected patch every morning and evening ; if there is 
much tenderness it must be omitted for a day or two. Once a week at least 
the ointment should be washed off with soft soap, and effects of treatment 
carefully noted. Oleate of mercury is especially suited for the diffuse form 
of ringworm ; it apparently penetrates better than iodine or carbolic acid, 
which tend to harden the epithelial tissues ; this power of penetration is 
obviously of great advantage when the fungus extensively affects the 
hair-roots. 

In the early stages, when there is a single circumscribed patch of ring- 
worm or only a few patches, some more powerful remedy than the 5 per 
cent, oleate of mercury may be used with advantage. The 10 per cent, 
ointment may be applied, or carbolic acid and glycerine (1-6 by measure) 
may be rubbed into the patches night and morning. Coster's paint (iodine 
5ij, oil of cade 5 v j) is a l so useful in recent cases painted on the patch, 
removing the crust every few days and reapplying. Glacial acetic acid and 
hydrarg. perchlorid. (gr. iv ad 3J) as used by Alder Smith are good appli- 
cations, as is also Auspitz's solution of chrysarobin in chloroform (F. 47). The 
last two must only be used to circumscribed small patches, and are not 
suitable for young children or those in whom inflammation is readily set up. 
It is well to keep the rest of the scalp well oiled with carbolic oil when strong 
applications are being applied to some local patch. A light skull-cap should 
be worn to prevent the ointment smearing the bed linen at night. 

While in the chronic or diffuse forms we prefer mercurial preparations, 
yet some cases appear benefited by a change, or at any rate a change of 
ointment will sometimes Avork wonders in the eyes of the friends. An 
ointment containing equal quantities of carbolic acid (Calvert's No. 2), ung. 
hyd. nitr., and ung. sulphuris (Alder Smith), is a good and useful one ; or the 
formula (F. 48) recommended by Jamieson. 



Scabies 745' 

Whatever form of application is adopted, it is tolerably certain that much 
patience will have to be exercised before the disease can be pronounced 
cured. Weeks and even months may elapse, and while progress has been 
made perhaps scurfmess and diseased stumps can be detected ; or, perhaps, 
while the disease appears eradicated in one place, it is spreading in another 
direction. 

Epilation is useful in all stages, but timid and young children are too 
nervous to submit to much being done in this way. In cases which have 
proved intractable and resisted all treatment for months a local patch of 
inflammation may be set up by means of croton oil. The usual method is 
to paint some croton oil on over a patch of half an inch to an inch in 
diameter, to repeat it the next day, and to follow it up by a poultice ; the 
patch becomes red and puffy, suppuration takes place about the hair 
follicles, and the hairs readily come out. To this boggy condition the term 
kerion is applied. It is important to apply this treatment to only small 
patches at a time. 

After the disease has been apparently cured it is well to continue for a 
time with some remedy containing a mild parasiticide. One of the formulae 
49 or 50 usually answers for this purpose. 

Alopecia Areata. — Alopecia consists of smooth, shining, bald patches on 
the scalp. It occurs at all ages, both of childhood and adult life. Its cause 
is uncertain, though there is a consensus of opinion that it is not due to any 
fungus. In some cases it follows severe headaches, in others there is 
no known cause, though it occurs mostly in those who are below par and 
out of health. It may occur first in patches, and perhaps after a while 
involve the whole scalp. It is extremely intractable, and little influenced by 
treatment local or constitutional. Cod-liver oil and tonics are usually given, 
and stimulating lotions, such as F. 51. 

Pavus. — Favus is not a common disease in this country, but is occasion- 
ally seen among out-patients at a children's hospital. It is known at once 
by the peculiar yellow cup-like depressions formed by the crusts, and by the 
peculiar ' mousy' smell. These crusts can be raised from the scalp by means 
of a blunt knife, carrying the hairs with them, leaving a pitted skin, which, 
however, crusts over again in ten or twelve days. The favus crusts may be 
present on the body as well as on the scalp. The subjects of this disease are 
generally cachectic and have been ill fed. The fungus— achorion Schonleinii 
— closely resembles the tricophyton of ringworm, but the mycelium is more 
jointed, and the gonidia are more numerous and larger, though they vary 
much in size. 

The disease is very chronic, frequently lasting for years. The treatment 
consists in removing the crusts, applying parasiticides, and administering 
cod-liver oil and iron. 

Scabies. — Scabies is very common in infants and children in dispensary 
practice, and by no means unknown among the well-to-do classes of society. 
Among the former there is rarely any difficulty in diagnosis, as they usually 
do not present themselves till the disease is well-marked and pustules have 
formed, while in private practice the diagnosis maybe difficult when the disease 
is local, as, for instance, on the hands. In infants and young children scabies 
gives rise to more irritation than in adults, and in infants at the breast urticaria 



746 Diseases of the Skin 

and erythema of a more or less severe nature may be frequently seen. In infants 
the hands may be quite free, while the face and legs or genitals may be 
affected. In cachectic or weakly children there are usually much crusting and 
many pustules, pus being transferred from one part to another by means of 
the finger-nails. The diagnosis is not usually difficult ; urticaria, simple 
eczema, and lichenous rashes may be mistaken for it. The presence of bur- 
rows, the irregular distribution of the vesicles and papules,' as well as the in- 
tense itching, are the characteristic points. We have, however, sometimes been 
in doubt regarding the nature of itching rashes present only on the backs of 
the hands. A cure is readily effected by a hot bath with the copious use of 
soft soap, followed by sulphur or storax ointment ; the bath and ointment 
should be repeated for four or five nights in succession, and the clothes should 
be stoved. (F. 52, 53, 54.) 

Simple Onychia in children may be looked upon as a variety of the 
subcuticular form of whitlow, in which the nail matrix is involved instead of 
the skin of the finger. It is usually the result of some slight injur} 7 such 
as nail-biting, running a splinter beneath the nail, or too close cutting 
of the nails. Early letting out of the matter and removal of foreign material, 
with subsequent warm water or lead lotion dressing, is all that is required. 
Occasionally suppuration goes on intractably beneath the nail, or recurs 
again and again after drying up ; in such cases the nail should be cut away 
over the inflamed spot, and the surface scraped clean, and some solid nitrate 
of silver applied. 

Onychia Maligna is a more formidable affection, nearly, if not quite, 
always due to injury of the finger end. The whole nail matrix becomes 
inflamed, the end of the finger is swollen, congested, and bulbous, the nail 
becomes loosened, curled up, and blackened, and there is much burning pain ; 
a dirty, sero-sanguineous, often foul discharge comes away, and the mischief 
may go on for months if neglected, and even give rise to necrosis of the ter- 
minal phalanx and permanent distortion or destruction of the nail. The 
treatment we have hardly ever found to fail is dusting the raw surface over 
with powdered nitrate of lead night and morning for a few days ; the nail 
should be removed if the disease has involved anything more than the upper 
part of the matrix. We have often seen onychia of many months' standing 
get practically well in a week under this treatment. Occasionally it is neces- 
sary to scrape away the diseased tissue and remove a sequestrum, but this is 
quite exceptional. 

Lupus. — Mention has already been made of superficial tuberculous ulcera- 
tion of the skin {vide p. 383), but the special form known as lupus vulgaris 
needs a short notice here. The affection consists in the development of 
small circular deposits of inflammatory material in the thickness of the true 
skin. These deposits, known as ' lupus tubercles,' are found usually in 
patches which tend to spread by the formation of new tubercles at the 
margin of the patch. At first isolated, after a while the tubercles coalesce and 
break down, forming a larger or smaller superficially ulcerated patch, which 
is usually coated over with thick scabs or crusts. In earlier stages there is 
no obvious ulceration, and a thin pellicle covers over each ' tubercle.' If 
allowed to spread, extensive destruction of the skin may occur, and the deeper 
structures are in certain cases attacked. It is, however, very rare for lupus 



Hairy and Pigmented Moles 747 

to penetrate through the deep fascia, and it probably never attacks bone. 
The most extensive destruction is usually of the nose, where the whole of the 
lateral and alar cartilages may be eaten away, leaving a short, pinched, and 
shrunken organ. Almost any part of the body may be attacked, but the face 
is the favourite seat, and especially the tip and sides of the nose. Less often 
the disease attacks the mucous membrane of the lips, cheeks, and septum nasi, 
and we have seen the tonsil and soft palate involved by extension from a patch 
of lupus at the angle of the mouth. Chronic in its course, and intractable to 
any but very thorough treatment, lupus is one of the most troublesome of 
the skin diseases met with in tuberculous subjects, especially as great de- 
formity and disfigurement are often produced by its ravages. On scraping 
out a ' lupus tubercle ' a hollow or pit is seen 
in the thickness of the dermis, while at the 
edge of the patch the superficial part of the 
skin is undermined. 

Treatment. — The general treatment is that 
of tuberculosis, cod-liver oil and arsenic being 
of especial value. Locally nothing is so effec- 
tual as thorough removal of the disease me- 
chanically. It is best to give an anaesthetic, 
and thoroughly scrape away and dig out all the 
soft tissue with a sharp spoon. All the material 
that can be scraped away should be removed ; 

healthy skin will not break down under the use Fi f nd ^y p H T la n r ° g e pit "of Ae 
of a Volkmann's spoon. After the scraping the patch was removed by the use of 

, ,. , r -l the actual cautery and nitric acid. 

actual cautery or solid nitrate of silver, or, 

better still, powdered nitrate of lead, may be applied, but the mechanical 
removal is the most important part of the process. There is free bleeding 
at the time, but this speedily stops. The sore should be dressed with iodo- 
form ointment, and a careful watch kept for the appearance of fresh tuber- 
cles, which should be at once attacked in the same way. The repeated 
application of powdered nitrate of lead has been very useful in our hands, 
both for lupus and other intractable tuberculous sores ; it is somewhat pain- 
ful but very effective. 

Papilloma. — Warts are very commonly met with on children's hands, 
and often appear in crops. They frequently disappear spontaneously, but if 
they are troublesome may be readily cured by some caustic application, or 
better by the steady use of salicylic collodion. 

Hairy and Pigmented EKoles occur congenitally, and sometimes cause 
great disfigurement, as in fig. 182. If small they maybe treated by excision. 
If extensive the growth maybe removed in sections by the application of 
the actual cautery or strong nitric acid, but it must be remembered that any 
of these methods necessarily leave a scar. Mere overgrowth of hair may 
be removed by electrolysis and epilation. 




748 Injuries, Shock, Hcemorrhage 



CHAPTER XXXVI. 

INJURIES, SHOCK, HEMORRHAGE, ETC. 

The various injuries met with in children can only be very briefly described 
here, and only those more or less peculiar to childhood will be mentioned. 

Injuries to the Head. — In young children it is not uncommon for one 
of the bones of the vault of the skull to be dinted or dinged in, and a well- 
marked but shallow saucer-like depression may be felt. Care must be taken 
to distinguish this lesion from cephalhematoma {vide p. 20). The symptoms 
of brain injury in such a case are usually those of concussion and often 
speedily pass off; recovery usually takes place without any bad symptoms, 
and the depression in most instances gradually becomes obliterated by 
pressure from within and modelling of the bone. 

The treatment of such cases is simply rest and quiet ; no operation is 
called for. Sometimes, however, where the depression is more abrupt and 
marked symptoms of compression exist, especially if the fracture is com- 
pound, the general lines of treatment for such cases in adults must be 
followed. In children the rule, however, is not to operate unless the fracture 
is compound. 

Traumatic Cepnalhydroeele is the name applied to a condition where 
there has been a simple fracture of the skull, with probably in all cases 
laceration of brain and laying open of one or other lateral ventricle. The 
fluid contained in the ventricle escapes beneath the scalp and forms a soft, 
fluctuating, usually pulsating swelling; this is distinguished from hematoma 
in some" cases by its later onset and steady increase. The swelling, how- 
ever, may appear immediately ; sometimes it is not found for some months 
after the injury ; in any doubtful case aspiration would settle the point. 

Cepnalhydroeele is most often met with in children under two years old, 
but may occur as late as the twelfth year ; it is most common in the parietal 
region. We have seen several of these cases. There is often extensive 
absorption of bone after the injury, so that a considerable gap is left in the 
skull. Hydrocephalus not rarely ensues. 

Treatment, &C. — Tapping appears to be of little use, 1 and pressure and 
quiet are the only treatment. A plastic operation has been proposed to close 
the aperture in the skull, and might possibly be advisable in any case that was 
clearly getting worse. 

The mortality is high : some 40 per cent, of the patients die ; in some 
instances temporary recovery takes place and meningitis develops later. 

1 Lucas, Guy's Rcpts. 1879 et seq. ; T. Smith, St. Bartk.'s Repts. 1884. Erichsen, 
Southam, Godlee, Howard, and Conner have recorded cases ; also Golding Bird, Guy's 
Repts. 1889. Year Book of Treatment, 1895, p. 226. 



Injuries of the Chest, Abdomen, &c. 749 

Occasionally after compound fracture of the vault a free escape of 
similar fluid occurs, as in one case of our own : there was a compound de- 
pressed fracture of the frontal bone, which required elevation ; an abundant 
flow of clear fluid took place from the wound before operation ; the boy 
recovered without any bad symptom. 

Fracture of the Base of the Skull in children is a much less serious 
injury than in adults, and is often completely recovered from. Traumatic 
meningitis is rare in children, and they generally recover well from con- 
cussion and brain laceration. 

Dr. Allen ('Lancet,' October 24, 1885) has described a fracture disloca- 
tion of the atlas occurring in infants ; the lesion is marked by hyper-extension 
of the head and a liability to ' epileptic fits ' on attempts at extension or 
pressure downwards upon the head. The injury is probably inflicted during 
parturition. Vide also Guerin, ' Gaz. Medic.,' 185 1. 

Injuries of the Chest. — The only fact about chest injuries that is 
peculiar to childhood is that, in consequence of the flexibility of the chest- 
wall, visceral lesions without fracture of the ribs are not uncommon. When 
rupture of the lung occurs the laceration is usually in the neighbourhood of 
the root of the lung, and the usual complications — emphysema, haemothorax, 
and haemoptysis — are often present, though the last is less often seen, since 
young children rarely expectorate, and the blood is swallowed. 

Injuries of the Abdomen have no peculiar features ; if the immediate 
shock is recovered from, subsequent complications are rarely fatal unless 
from some severe visceral laceration. 

Fracture of the pelvis in childhood is less likely to be complicated by 
v sceral injuries than in adults, since sub-periosteal fractures and separation 
of epiphyses take place in children. We have met with a case of fractured 
pelvis in which the urethra was separated from its normal position beneath 
the pubic arch and displaced backwards towards the anus, the injury 
occurring in a little girl. 

Rupture of the membranous or spongy urethra is not uncommonly met 
with in boys as a result of falling astride some projecting edge, e.g. the top 
of palings or of a gate, or the bough of a tree. The symptoms are pain and 
swelling in the perinasum, escape of blood from the urethra, inability to pass 
urine, and distension of the bladder unless it has been recently emptied. 
A gentle attempt should at once be made to pass a catheter ; if this succeeds, 
the instrument should be tied in for three or four days and then changed ; 
after a week or ten days it is sufficient to pass a full-sized catheter daily. 
This is the orthodox treatment, but a traumatic stricture usually results, 
requiring the passage of instruments frequently throughout life. Extravasa- 
tion of urine often occurs either immediately or within a day or two of the 
accident, and necessitates free incisions into all the infiltrated parts. To 
avoid these misfortunes probably the best plan is, immediately after the 
accident, to cut down upon and suture together the ends of the torn urethra. 
This we have done with excellent results in adults, and, as a secondary 
operation, in a child. 

Injuries of the Xiimbs. — The peculiarities of injuries to the limb bones 
in children depend mainly upon two facts. 1. The bones of children are 
soft, contain relatively little earthy matter, and are therefore less brittle 



750 Injuries, Shock, H&morrJiage, &c. 

than those of adults. 2. The epiphyses are yet ununited, and the periosteum 
is thicker, more easily detached, and more freely supplied with blood than 
in older people. 

Greenstick Fractures. — A greenstick fracture is one where more or 
less of the thickness of a bone has bent and yielded instead of snapping- 
across ; there is probably really always a fracture. Simple bending of bone 
without fracture is of doubtful occurrence, in health at least, though it may 
occur in rickets and osteomalacia. Many fractures in children are sub- 
periosteal, and to this fact and to the incompleteness of the fracture is due the 
absence of marked symptoms in many cases, so that fractures are not rarely 
overlooked ; indeed, deformity, obvious mobility, and crepitus may all be 
absent, and it is common enough to see a fractured clavicle of a week's or a 
fortnight's standing, or even longer, in which the first sign that attracted 
the parent's attention was the 'lump in the neck,' consisting of callus round 
the fractured ends. Hence, after any severe injury, each part and limb 
should be systematically searched, especially in very young children, for all 
probable injuries. The treatment of greenstick fractures is the same as for 
ordinary fractures, any displacement being at once forcibly reduced. 

Ununited Fractures. — -Fractures in children usually unite well, and even 
in rickety patients non-union is rare. We have already mentioned cases of 
non-union in fracture after necrosis of the tibia and humerus. Occasionally 
one or more of the long bones is fractured at or shortly after birth, or even 
in utero, and in these cases non-union is not very rarely met with. It is a 
curious fact that such fractures have almost universally resisted all attempts 
to procure union when once the ends of the bones have become atrophied 
and a false joint has formed. Sir James Paget has pointed out this pecu- 
liarity. 1 In one of our patients we tried many methods before obtaining 
union, as will be seen below. 

Case. — John H., at six weeks old, was found to have a fracture of the leg, but it was 
not known how long it had existed. The mother had a fall two months before he was 
born. On admission there was an old ununited fracture of both bones of the right leg 
1^ inch above the ankle ; the limb was loose and almost flail-like. In May 1889 the 
ends of the bones were resected, and the tibia wired ; no union followed. He was re- 
admitted in July and plaster of Paris reapplied. In October the ends, which were much 
atrophied, were again resected, and ten pieces of bone, taken from the femur of a freshly 
killed young rabbit, were grafted in. The wound healed by primary union, and the limb 
was put up in plaster. No union nor even any formation of callus followed. In January 
1890 the operation was repeated ; eight grafts being inserted, the wound was closed and 
the limb put up in plaster. Three pieces of the rabbit's bone were removed in April and 
May, and the wound healed. In June the wound was reopened, and a long piece of rabbit's 
femur wedged in between the ends. The wound healed at once, and a good deal of thick- 
ening, but no real union, followed. In April 1891 the wound was reopened and the large 
piece of rabbit's bone found bare and encysted in a cavity containing clear yellow fluid ; 
smaller pieces were found embedded in fibrous tissue ; there was no sign of any septic 
condition. The rabbit's bone was removed and the ends of the tibia freshened ; an inch 
of the fibula of the same leg was then taken from just below its head and fitted in between 
the ends of the tibia. No union followed, and in September 1891 the ends were again 
resected, and stout steel pins driven crosswise through the fragments, which, by reason of 
the shortening of the fibula, could be brought well into apposition. Round the ends of 
the pins silver wire was wrapped as in a harelip suture ; the wound was closed and the 

1 Studies from Old Case Books, 1891. 



Separation of Epiphyses 7 5 \ 

limb fixed in plaster. In December 1891 the plaster was removed, and the bones were 
found united ; one of the pins was removed and the limb fixed in plaster of Paris. The 
union was firm when the limb was examined in August 1892, and the wound was quite 
sound, but the limb was still weak, and no restoration of the fibula had taken place. 
D'Arcy Power has collected a series of 72 cases ; Jn 45 of these, attempts to obtain union 
failed. ('Med. Chir. Trans.,' vol. lxxv.) 

Separation of Epiphyses. — It has been well established by Holmes and 
others, especially by the French surgeons, that a pure epiphysial separation 
is very rare ; the condition is nearly always a combination of separation of 
the epiphysis with a fracture of the shaft ; that is, the line of separation runs 
partly through cartilage and partly through bone. The periosteum in many 
of these cases remains untorn, and, as Mr. Hutchinson has shown, it is in 
many instances extensively stripped up from the diaphysis, and necrosis may 
follow. Hence the symptoms of epiphysial separation or diastasis vary con- 
siderably ; thus there may be little or no displacement, crepitus may be absent, 
or very indistinct ; and undue mobility may be only recognisable on very 
careful manipulation. We have seen many cases in which there has been 
a history of previous injury, supposed to be a strain, in which the amount of 
thickening found at the time of examination makes it almost certain that a 
more or less complete separation of an epiphysis had occurred. This is espe- 
cially common about the lower end of the humerus, and our experience fully 
bears out Mr. Hutchinson's statement that these accidents are exceedingly 
common, and in any doubtful case of injury about the elbow they should 
always be suspected. Curiously Hamilton (' Fractures and Dislocations ; ) 
says he has never met with a case. It is, however, possible that in some 
instances the violence may strip up muscles and the thick loose periosteum 
without any fracture or diastasis, and this injury of the periosteum may be 
the cause of the subsequent thickening. 

In well-marked cases there are deformity, undue mobility, loss of power, 
and sometimes indistinct or so-called 'false' or ' dummy' crepitus ; the outlines 
of the fragments are more rounded than in ordinary fracture, and the line of 
separation coincides with that of an epiphysis. It must be remembered that 
an epiphysial junction is not a flat, plane surface, but there is in most of the 
bones a cup-shaped hollow in the epiphysis which receives the rounded con- 
vex end of the shaft. It is often difficult to reduce and keep in place the 
fragments, and a certain amount of deformity is often persistent, though this 
diminishes by a gradual process of modelling as time goes on. Arrest of 
growth occurs in some cases, not in others ; probably this depends upon the 
accuracy with which the lesion has followed the epiphysial line, and the 
amount of destruction of the growing bone or of premature synostosis that 
results. Occasionally acute necrosis of a separated epiphysis occurs, or at 
least acute suppuration around it, and this is said to be disproportionately 
frequent in cases of separation of the epiphysis of the great trochanter. 
(Hutchinson, junior.) These injuries are most common about the two ends 
of the humerus, the lower end of the radius, and the lower end oi' the femur. 
It is sometimes said that separation of the lower end of the femur is the 
most frequent accident, but in our experience it is not nearly so common as 
the diastasis of the humerus. We have once met with diastasis o\ the upper 
femoral epiphysis {vide 'Hip Disease in Childhood, 3 by one o\ the pic- 



752 



Injuries, Shock, Hcemorrhage, 



&c. 



i 



^T-; 






writers) ; l occasionally diastases are met with at the upper end of the tibia, 2 
and elsewhere. 3 Tubby 4 has collected cases of separation of the clavicular 
epiphysis. The diagnosis depends upon the age of the patient, the fact that 
the projecting edge of the bone is sharp and unlike the natural inner end 

of the clavicle as it would be in 
the case of a dislocation, and 
also in that a lamella of bone 
can be felt between the sternal 
notch and the end of the shaft. 
It must be remembered that the 
epiphysis is only an extremely 
thin plate. The treatment is 
that of fractured clavicle. 

According to Tubby separa- 
tion of the coracoid epiphysis is 
of extreme rarity, and no case 
of separation of the acromial 
epiphysis appears to be authen- 
tic. 

Diastasis of the upper end of 
the humerus is not rarely met 
with. It results from injuries 
such as blows or falls upon the 
arm, which, in the adult, would 
probably cause either fracture of 
the shaft or dislocation of the 
jjjjr -^RlSlI -Hi shoulder. The appearance of 

'' the shoulder is characteristic, 
though much like that of fracture 
of the surgical neck of the bone. 
There is no depression below 
the acromion, but some flattening 
a little lower down, with a marked 
prominence on the anterior and 
inner aspect of the arm, a short 
distance below the coracoid process. This prominence is the upper end of 
the shaft of the humerus displaced forwards and inwards ; the edges of the 
projecting bone are more rounded, and less sharp and irregular than in the 
case of fractured surgical neck, and on reduction, which is usually, though 
with difficulty, managed, ' dummy' crepitus instead of that of a true fracture 
is felt. It is difficult to keep the fragments in position, but, as the surfaces 




Fig. 



-Separation of the upper Epiphysis of the 
Right Humerus. 



i See also Stimson on Fractures, and Hutchinson, Arch, of Surgery, April 1892, and 
Tubby, Annals of Surgery, 1894, vol. xix. 

2 Separation of the upper epiphysis of the tibia has been caused by the bad practice of 
applying extension for hip disease below the knee instead of above it. 

5 For"an account of separation of epiphyses due to congenital syphilis (syphilitic telos- 
titis) vide chapters on ' Congenital Syphilis' and on ' Bone Diseases.' Similar multiple 
separations may be the result of so-called ' scurvy rickets.' 

* Guy's Reports, 1889. 



Separation of Epiphyses 



753 



are broad, there is very rarely or never any actual overlapping. Since the 
upper epiphysis of the humerus includes the tuberosities, there is abundant 
blood supply to the upper fragment, and union usually takes place speedily. 
The treatment consists in applying a long inside angular splint, well padded 
at the top and fitting high up into the axilla. The fragments are brought 
into position, and a felt or gutta-percha shoulder-cap is then moulded on. 
Passive movement should be begun in ten days. The deformity is rarely 
entirely reduced, but good union and a useful though possibly somewhat 
shortened limb result. The injury may be compound or complicated with 
rupture of the axillary artery. Instances of non-union have been met with, 
and shortening to the extent of five inches ten years after the injury. In 
some cases carrying the arm 'forwards and upwards to the perpendicular 
line' — Moore quoted by Tubby 

Epiphyses of Head 8c) A, e 



Tuberosities II end at 
5*$- yV and unite 
wi'tA Shaft at ZO^u 



— will render reduction easy. 

Separation of the lower epi- 
physis of the humerus is, we think, 
far the commonest lesion of the 
kind met with in children. We 
believe the most frequent injury is 
separation of the inner condyle, 
i.e. the epiphysis of the trochlea 
together with that of the epicon- 
dyle. J. Hutchinson, jun., thinks 
separation of the inner epicon- 
dyle is the most frequent lesion, 
and that it never becomes united 
by bone when once separated. 
The line of disjunction runs 
from above the condyle into the 
joint between the trochlea and 
capitellum. It is very common to 
have children brought with an 
injury to the elbow of some days' 
duration, and a statement that the 
limb has been strained or the 
joint put out. On examination 
there is pain and restricted move- 
ment about the elbow joint, but 
the olecranon, the head of the 
radius, and the internal condyle 
occupy their normal relations to 
one another. Sometimes, how- 
ever, the disaster is accompanied 
by dislocation of the joint, and 
paralysis of the ulnar nerve may 

be met with. On grasping the lower end of the humerus between the linger 
and thumb, marked thickening as compared with the other side is fell 
usually just about the internal condyle. Sometimes the whole lower epi- 
physis is separated and displaced backwards ; less often the capitellum and 

\ C 




elopment of the Humerus 
rom Gray's . I <i 



754 



Injuries, Shock, Hemorrhage, &c. 



outer condyle are detached. Such cases, if seen at once, should be treated, 
after reduction of any obvious deformity, by gutta-percha or Gooch splint, 
on one side, and on the other an angular splint, reaching from the shoulder 
to the end of the fingers. Treatment of these injuries of the lower end of 
the humerus by keeping the arm extended has been recommended as tending 
to diminish the displacement due to contraction of the triceps and the ten- 
dency to tilting of the fragments, but this method of treatment has not 
become the accepted one. H. O. Thomas, R. Jones, and others recommend 
treatment by supination and extension, followed by acute flexion of the 
elbow. 1 At the end of a week the splints should be removed, gentle active 





Fig. 185. —Separation of trochlear epiphysis of humerus, showing 
adduction of the forearm with loss of the ' carrying angle.' 



Fig. 186. — Arrest of growth 
of the radius from separa- 
tion of the lower epiphysis 
many years before. 



movement encouraged, and the splints readjusted. A week later all splints 
should be left offand the arm worn in a sling, but taken out night and morning 
for gentle exercise. Violent passive movement to keep up flexibility is mis- 
chievous and delays the cure, since the irritation increases the amount of 
callus thrown out. If no passive or forcible movement is allowed, but just 
gentle voluntary exercise, absorption of all thickening gradually takes place, 
and provided the displacement has been fairly corrected, almost perfect 
mobility will return in the course of a few months. The great point in 
treatment is to reduce the deformity and avoid forcible movement, but en- 
1 Brit. Med. Jour. January 23, 1892, and November 3, 1894. 



Sepa7'ation of Epiphyses 



755 



courage gentle active movements after about the end of the first week. The 
ultimate prognosis is good as regards mobility, though uncertain as to arrest 
of growth. It occasionally happens that after separation of the whole lower 
humeral epiphysis union takes place with the lower segment of the limb 
adducted, i.e. there is loss of the ( carrying angle,' and an unsightly and 
somewhat awkward limb {vide fig. 185). In one case we twice osteotomised 
the humerus to remedy the deformity, which, however, recurred. Separation 
of the ulnar epiphysis is occasionally met with, and we have once wired a 
case of compound separation of the upper epiphysis with a good result. 

Separation of the lower epiphysis of the radius with fracture of the ulna 
is said to differ from Colles's fracture in that the palmar projection is more 
•obvious, the hand is not held so obliquely, i.e. there is not so much radial ad- 
duction, and the dorsal groove is horizontal instead of oblique. There is more 
resemblance to dislocation of the carpus backwards, but this is an exceedingly 
rare injury, and in it the styloid processes do not maintain their normal re- 
lations to the carpus as they do in fracture, while the age of the patient and 
the sensation of crepitus, together with the ease of reduction, but ready re- 
newal of deformity, will point to diastasis. 1 If the ulna is not fractured the 
resemblance to Colles's fracture is very close, and 
the treatment is the same. For cases illustrating 
these injuries in the upper extremities we must refer 
to Mr. Tubby' s paper. Arrest of growth may follow 
(fig. 186). Very rarely the upper epiphysis of the 
radius is detached. We have once met with a 
case of separation of the symphysis pubis asso- 
ciated with rupture of the urethra. 

In separation of the lower epiphysis of the femur 
the lower fragment is usually displaced forwards, 
and the backward pressure of the diaphysis upon 
the vessels may cause gangrene, as in cases of 
Wheelhouse's, and McGilPs of Leeds. 3 We have 
seen cases of compound separation of the lower 
epiphysis with similar displacement. The dis- 
placement should be rectified under chloroform, 
and the limb put upon a Macintyre's splint or an 
inclined plane. If necessary, the part should be 
•exposed by operation and the deformity reduced. 
In many cases the onset of gangrene appears to 
have necessitated amputation. 3 The displacement 
is occasionally lateral. 

In separation of the upper epiphysis of the 
tibia, which is exceedingly rare, according to 

Tubby the epiphysis is displaced backwards and the deformity tends to recur 
after reduction. We have seen a remarkable case of separation of the lower 
epiphysis of the tibia in a boy of about ten years, who was under the care 

1 Vide R. W. Smith on Fractures and Dislocations. 
'-' BHt. Med. Jour. May 24, 1884. 

5 Mayo Robson, Annals of Surgery, 1893, vol. win. ; Tubby, Ann ah 
1894, vol. xi\. 

3C2 




Fig. 187. — Separation of lower 
epiphysis of left femur. The 
epiphysis is displaced for- 
wards, and the knee is 
Hexed. 



756 Injuries, Shock, Hemorrhage, &c. 

of our colleague Mr. Hardie. The case was complicated by the presence 
of a vertical fracture running upwards from the epiphysial line. The foot 
and lower fragment were displaced outwards, and the deformity could not 
be reduced until some weeks after the accident, when the ends of the bone 
were exposed by operation and with some difficulty replaced. We have 
also met with an instance of compound separation of the lower epiphysis 
of the fibula. The lower fragment became necrosed and was removed. 

The diagnosis of epiphysial separations need not be further described 
here : the locality, age of the patient, and the symptoms mentioned usually 
make the case clear, and any injury in the neighbourhood of a joint of doubt- 
ful character should be treated as if a diastasis had occurred. After a few 
days the subsidence of the general swelling and the presence or absence of 
callus will clear up the doubt, even if a careful examination under chloro- 
form fails to reveal the exact nature of the injury. 

For further details, with records of cases, we must refer to Mr. Tubby" s 
interesting papers, and to Mr. J. Hutchinson's, jun., Lectures, published in the- 
' British Medical Journal,' 1893-94. 

The treatment of these cases is simply that of a fracture in the same 
position, though lighter appliances may of course be used in the case of 
children than of adults ; thus poroplastic felt, Gooch's splint, Hide's felt, 
gutta-percha or light wooden splints may be employed. Most careful padding 
is necessary in all cases to protect the tender skin ; absorbent wool will be 
found the best material for this purpose. 

In separation of the lower epiphysis of the femur, as already stated, the 
limb should be put up in the flexed position, since the gastrocnemius, whether 
attached to the upper or lower fragment, tends to tilt the ends of the bone. 

Stimson mentions that Volkmann has three times separated the lower 
epiphysis of the femur in manipulations required in cases of hip disease ; we 
once met with the same mishap in a case of acute suppurative arthritis in an 
infant. The ease with which diastasis occurred was probably due to inflam- 
matory or atrophic softening of the epiphysial line. The child recovered 
without arrest of growth. 

In all cases a guarded opinion should be given as to the future mobility 
of the adjacent joint, and movement should be begun early — in the case of 
the elbow not later than the end of the first week, the splints being reapplied 
afterwards, and movement employed daily after the first fortnight ; a week 
longer may be given for other joints. No forcible passive movement should 
be employed ; if the fragments have been replaced it is unnecessary and even 
harmful ; if they are still out of position, forcible movement is useless ; and 
if, after time has been given for absorption and modelling down of the parts, 
the limb is still seriously crippled, it is probably better either to resect the 
joint or to cut down upon and chisel away any projecting fragments of bone. 
Hence, if it is found that the thickening does not subside it is well to cease 
movement and allow the parts to settle down, and mobility will probably 
return without any special effort. Separated epiphyses unite with great 
rapidity, much more so than fractures. Even if there are considerable thick- 
ening and distortion for some weeks after the injury, and perhaps con- 
siderable loss of power and mobility, so much modelling of the parts takes 
place that ultimately the result is usually good. 



Fractures 757 

In cases of compound separation of an epiphysis it may be necessary to 
resect part of the shaft of the long bone in order to reduce the displacement. 
Even in such cases the amount of ultimate shortening may be very little, though 
it is quite uncertain how much it will be. 

Implication of the musculo-spiral nerve in the callus of a separated lower 
epiphysis of the humerus is not uncommon, and there may be paralysis of 
the nerve for a time ; usually, however, this disappears, and no hasty opera- 
tion for the release of the nerve is called for. 

The following table of the dates of ossification and union of the epiphyses 
of the principal long bones is inserted from Quain's 'Anatomy : ' 

Humerus. 

Nucleus of head appears in second year. 

„ capitellum appears in third year. 

„ internal condyle appears in fifth year. 

„ trochlea appears in eleventh to twelfth year. 

„ external condyle appears in thirteenth to fourteenth 
year. 
The lower epiphyses unite with shaft in sixteenth to eighteenth 

year. 
The upper epiphysis unites with shaft in twentieth year. 1 

Radius. 
Nucleus of lower extremity appears at end of second year. 

„ head appears in fifth year. 
Upper epiphysis and shaft join in seventeenth to eighteenth year. 
Lower epiphysis and shaft join in twentieth year. 

Femur. 
Nucleus of lower end appears at ninth month. 

„ head appears at end of first year. 
Head joins shaft at eighteenth or nineteenth year. 
Lower epiphysis joins shaft after twentieth year. 

Tibia . 
Upper epiphysis appears about time of birth. 
Lower epiphysis appears in second year. 
Lower epiphysis joins shaft in eighteenth to nineteenth year. 
Upper epiphysis joins shaft in twenty-first or twenty-second year. 

Further details in regard to the important subject of disjunction of 
epiphyses will be found in the papers of Messrs. Tubby and Hutchinson 
already referred to. 

Simple complete fractures of the long bones may be met with at any 
age, and even occur sometimes in utero ; indeed, compound fractures may 
occur before birth. Intra-uteririe fractures may be the result of falls or ot 
blows upon the mother's abdomen, or of muscular contraction, and are some- 
times associated with intra-uterine rickets. Almost any number of fractures 

1 Stimson says sometimes as late as the twenty-fifth year. 



758 Injuries, Shock, Hemorrhage, &c. 

may thus occur ; 200 were found in one instance and 113 in another. Such 
fractures may be found united at birth ; they are not very rarely produced 
during labour by instruments or traction upon a limb. 

Fractures of the clavicle in quite young children are best treated by a 
flannel bandage to fix the arm to the side with the hand on the opposite 
shoulder, and a soft pad of absorbent wool in the axilla. The child's arm 
is, of course, kept inside its clothes, and not put through a sleeve ; as Mr. 
Owen suggests, a jersey may be usefully worn over the bandage to keep the 
limb quiet. In this, as in all fractures, it is an excellent plan to keep the 
skin well powdered with boracic acid or sanitary rose powder, so as to prevent 
irritation of the skin. 

Fractures of the arm are treated in the ordinary way : the splints should 
always be carried well up to the ends of the fingers to prevent disturbance 
of the fragments by the restless movements of children. We are well aware 
that this is not usually recommended, but we believe it to be the proper, as 
it certainly is the anatomically correct plan. Fractures of the pelvis are 
treated by bandaging the legs together firmly with a broad flannel bandage, 
which is carried upwards to above the crests of the ilia, the child being, of 
course, kept in bed. 

In fractures of the femur in babies under a year old a piece of gutta- 
percha or Gooch's x splint, lined with wool, should be applied to the thigh., 
and the legs bandaged together with a flannel bandage ; this is, we think,, 
the simplest, cleanest, and, on the whole, most effectual plan, though a good 
result may be obtained by almost any method. In older children, up to the 
third or fourth year, we prefer the vertical suspension plan, as more cleanly 
and efficient, and less troublesome after it is once applied than othermethods ; 
simple extension by a weight, with Gooch's splint, or an outside long splint,, 
is, however, satisfactory, and a Croft's, a Bavarian, or a Thomas's hip splint 
should be applied at the end of a fortnight. Thomas's knee splint may also- 
be used very successfully in fractures of the lower half of the femur. 

After fracture of the thigh in simple cases there should not be at most 
more than half an inch shortening in young children, and this will very 
likely disappear after a time. 

Fractures of the leg should be treated by a back splint with a foot-piece 
and two side splints for the first ten days or a fortnight, or more, according 
to age, and then one of the forms of stiff apparatus applied. 

In all cases the most careful watch must be kept for tight bandages ; no 
bandage should ever be applied beneath a splint, nor should a limb be ever 
bandaged in extension and then put up in flexion. Pressure sores and 
gangrene are real dangers in children. 

As is well known, any cause, such as hip disease, infantile paralysis, old 
anchylosis with atrophied bone, rickets, and so on, may produce weakening 
of the limb and may predispose to fractures from slight violence. When 
extensive necrosis has occurred, a slight injury may produce a fracture in 
childhood ; this usually unites well, but in some cases union is tedious, and 
in others does not occur : in such cases resection and wiring is a successful 
operation in our experience, but if the fracture remains long ununited the 

1 Commonly known as ' kettle-holder ' splint. 



Dislocations 759 

wasting of the fragments is apt to be extreme, and in one instance the upper 
fragment of the humerus was so small that it was found impossible to steady 
it sufficiently to obtain union. Macewen has dealt with such a case most suc- 
cessfully by transplantation of bone {vide ' Ununited Fractures'). This bony 
atrophy should always be borne in mind when dealing with such limbs. 

Mal-united fractures, if recent, and especially if greenstick, should be 
refractured at once ; if seen after three or four weeks, and when union has 
occurred, gradual reduction with splints often produces good results. Failing 
this, refracture or osteotomy may be called for. 

Primary Amputations in children are very rarely required, and conser- 
vatism should be carried to extreme limits ; when amputation is necessary, 
if the immediate shock is got over, recovery is usually rapid. We have had 
once to perform a primary amputation at the hip in a child five years old for 
a tramcar injury, and, though there was much ' prostration with excitement ' 
for the first two days, he ultimately did well. 

Primary Resections of joints are occasionally required, and in cases of 
injury to the elbow are spoken very highly of by Mr. Holmes. The need for 
them is, however, now exceedingly rare. 

Dislocations. — Almost the only dislocation at all common in children 
is that of the elbow — both bones being displaced backwards. This is usually 
said, and we believe correctly, to be more frequently met with in childhood 
than in adult life. Dislocation of the elbow is, however, often complicated 
with separation of epiphyses or fractures, and the displacement is often not 
directly backwards, but backwards and laterally, either inwards or outwards. 
Passive movement should be begun at the end of a week at latest. 

Dr. W. T. Clegg, of Liverpool, has sent us a case of subspinous dislocation 
of the shoulder, probably caused at birth ; this is the only case we have seen. 

Subluxation of the head of the radius is often met with in children as a 
result of lifting the child by one arm, swinging it round, or dragging it along. 
The head of the radius slips partially out of the orbicular ligament, and the 
arm is found to be fixed, powerless, somewhat flexed and pronated ; there is 
usually pain both at the elbow and wrist, so that sometimes the injury has 
been thought to be situated at the wrist joint. Reduction is effected by 
steadying the upper arm, and, with the thumb over the head of the radius, 
supinating sharply, and then flexing the forearm upon the arm ; sometimes 
a distinct click is felt or heard, and the power of using the arm at once 
returns. 1 

We have only rarely met with a traumatic dislocation (dorsal) of the hip 
in children. Reduction is easy by manipulation. Dislocation of the patella 
is occasionally met with ; there appears to be usually some congenital weak- 
ness of the part as a predisposing cause, as in the case appended. 

Case. — Dislocation of Patella. — Mary Alice N., aged 7 years 6 months; admitted 
February 7, 1883. History : Not strong, did not walk till three years old ; seven months 
ago fell while dancing and dislocated the left patella outwards ; since then has boon con- 
stantly falling on account of the displacement recurring, especially if she runs ; the injury 
caused her no great trouble for a week, when the displacement was noticed ; was treated 
as an out-patient for some time, with pads and various appliances to keep the patella in 



1 This injury has been specially described by Mr. Jonathan Hutchinson, jun. , and by 
Drs. McNab and Lindeman, Brit Med. Jour. Decembers, 1885. 



760 



Injuries, Shock, Haemorrhage, &c. 



place, but without success. On admission, the left patella during flexion lies quite on the 
outer side of the external condyle, coming back to its normal position on extension ; both 
femora have their external condyles very prominent ; no pain on manipulation or move- 
ment ; the patella was unnaturally small and could easily be moved about from side to 
side ; when walking it sometimes maintained its proper position, and then without warn- 
ing would slip quite over the outer condyle and make the leg yield. February 17, a 
lateral incision was made over the inner side of the joint down to the capsule, the patella 
pushed strongly inwards, and two catgut sutures, passed through the inner edge of the 
patella, were tied firmly down to the tissues on the inner side of the joint ; operation 
antiseptic ; back splint. 19th, has had a little pain ; did quite well ; antiseptics left off 
on March 3, and she was sent out in plaster of Paris splint on the 5th. Seen January 
1884, the patella keeps its place and the knee does not trouble her. In this case the 
patella was apparently congenitally small and ill developed, and this probably accounts 
for the condition. 



Subluxation of the knee has been recently described by Mr. H. B. 
Robinson as occurring in children about twelve months old, and apparently 
the result of relaxed muscles and ligaments. The tibia becomes displaced 

outwards, and rotated 
out on attempts being 
made to walk. Atten- 
tion to the general 
health and friction are 
the only modes of 
treatment required, 
and the tendency to 
displacement disap- 
pears as the child 
grows stronger. 1 

Congenital Dislo- 
cations are considered 
under the head of Mal- 
formations (p. 656). 

Injuries of the 
Soft Parts in children 
require no special no- 
tice ; if the immediate 
shock is got over, such 
wounds usually heal 
with great rapidity, 
even if very severe, and 
nothing short of actual 
gangrene (Holmes) should be considered justification for amputation. 
Warmth, opium in small doses, and free stimulation are specially required 
for all severe injuries in children. 

Burns and Scalds are exceedingly fatal, chiefly from shock, lung com- 
plications, and cerebral effusion. If the first few days can be tided over, 
recovery is usually satisfactory, and much more rapid than in adults. Care- 
ful watch for cicatricial contraction must be kept up, and provision made 




Fig. 1 



-Dislocation of the Patella, 
to the displaced bone. 



a points 



Brit. Med. Jour. July 27, 



S J lock — Loss of Blood j6i 

against it by suitable extension apparatus and manipulation, as well as by 
grafting. Plastic operations may be required at a later date. 

Shock. — The question of how children bear the shock of severe injuries 
or operations, and the effects of loss of blood and of pain, is one of much 
importance to the surgeon, and may be shortly considered here. First, then, 
as regards operations in infants and quite young children one great depressing 
■element is removed. They do not anticipate and are not cast down by the 
thought of the effect upon their future usefulness of any mutilation. In some- 
what older children anticipation of pain is of course keen, but it seldom de- 
presses in the same way that it does in adults. Again, the temperament of 
children is usually mobile, and, even if mental depression occurs, it is not 
long lasting. So with shock from a severe injury or operation the symptoms 
are often severe, even more so than in adults, for a short time ; but, if by 
means of stimulants the first few hours can be got over, children very 
quickly rally. It is common to have a great amount of shock in a child 
after such an operation as an amputation or excision of one of the larger 
joints, and yet the next day the child is often as bright as if nothing had 
happened. On the other hand, occasionally we see ' prostration with excite- 
ment' in a severe form in children, and we have known a mental condition 
practically identical with acute mania coming on after amputation at the 
shoulder joint, and lasting for some weeks, followed by complete recovery. 

Loss of blood is always very ill borne by children, and the more so the 
younger the child. Still, recovery is rapid if the child survives. Even the 
small quantity lost in a harelip operation sometimes seriously endangers 
the life of an infant a few weeks old, and in all cases great care should be 
taken to avoid haemorrhage as much as possible. The only instance of 
death from amputation at the hip joint that we have had in a child was in 
one where, from removal of a large part of the pelvis, free oozing took place. 

Next to loss of blood we should put cold as having the most depressing- 
effect upon children, and this should always be carefully guarded against by 
exposing as little as possible of the body beyond that part actually being- 
operated upon. 

Pain, if really severe, very seriously depresses a child, far more so 
than it does an adult, and many of the cases of severe burn die speedily 
from the combined effects of pain and fright. Hence, no child should be 
allowed to lie in pain after an operation, and opium should be given freely 
for a few hours till the first soreness has passed off, bearing in mind, 
of course, that opium has a disproportionately strong effect upon children, 
and that some children bear much smaller doses than others. The general 
rules, then, to be followed as to the management of surgical cases in 
childhood arc : (i) Do not let a child know that he is going to be 
operated upon, until the time actually comes for the operation. (2) Avoid 
with the utmost care unnecessary loss of blood. (3) Keep the child warmly 
wrapped up. (4) Never let a child suffer pain if it can be avoided :. thus, an 
anaesthetic should be given for any painful dressing or manipulation, and 
opium as soon as recovery from the anaesthetic has taken place. 

As Mr, Holmes lias well pointed out, in children 'irritability is chiefly 
directed against sudden and acute pain : but confinement to bed and 
protracted disease, which wear out the patience and exhaust the hopes oi 



762 Injuries, Shock, Hemorrhage, &c. 

older persons, soon become customary in childhood, and then produce little 
impression.' As Mr. Holmes shows, freedom from mental depression and 
healthy, unimpaired excretory organs probably account for this difference. 

Children are, of course, liable to the same septic diseases as adults, and 
pyaemia is, though happily rare in both, quite as common in childhood as in 
older patients. Diphtheria, and especially scarlet fever {vide Chap. XIV.), 
are very apt to attack surgical cases among children, i.e. those in whom there 
is a wound or a local inflammatory focus, while erysipelas, though not very 
rare and occasionally fatal, is mostly of a mild type in children, and in our 
experience the so-called ' erysipelas vagans ' is the variety most commonly 
met with. See, however, Vaccination Erysipelas, p. 261. 

' Surgical scarlet fever,' so called, is nothing more than ordinary scarlet 
fever. It is now well known that children who have open wounds, who have 
been recently operated upon, or who have local inflammatory foci, such as 
abscesses, are specially susceptible to scarlet fever. For further details and 
references we must refer to papers by Dr. Goodhart and Messrs. Howse 
and Paley, in the ' Guy's Hosp. Repts.' for 1879, and to an account of an out- 
break in our own surgical ward, by R. W. Murray, in the ' Brit. Med. Jour.' 
June 18, 1887. 

No special remarks are required upon the subject of dressing wounds in 
children ; the same rules should be followed as in adults. We use anti- 
septics — chiefly boracic and mercurial lotions, with iodoform and sublimate 
wood-wool wadding — and are fully satisfied of the value of these agents. 
Mercurial poisoning in children we have not certainly met with, and only 
iodoform poisoning in a few instances, and those of a very mild type. We 
have twice had a fatal result follow within twenty-four hours of emptying 
and washing out a large abscess, but we have been unable to connect the 
death definitely with the use of any particular antiseptic agent, though we 
have suspected perchloride of mercury of being dangerous in such cases. 

In certain cases — for instance, in circumcision — it is well to avoid the 
fright of a second manipulation by the use of catgut sutures in closing the 
wound, and it may be remarked that primary union of wounds in children is 
much more easily obtained than in adults, provided the child is healthy and 
not too young ; in the very young the tissues are too soft to bear any strain, 
and in childhood the very smallest disturbance of health is sometimes 
enough to prevent union of a wound ; hence all plastic operations should be 
performed only after careful inquiry into the child's general condition. The 
same slight causes will often produce a temperature chart that would be very 
alarming if it were not known how little is required to raise a child's tempe- 
rature. As to the dieting of children after operations, it will be found that 
children can without harm much more speedily return to their ordinary 
diet than can adults, and it is common for a child to resume its usual food 
the day after an operation. 

We have two or three times met with cases of persistent vomiting after 
operation resisting all treatment and even proving fatal by exhaustion. In 
one instance, after operation for cleft palate, the vomiting was followed by 
purpura, gangrene of the extremities, endocarditis, and death from acute 
septicaemia. 



763 



CHAPTER XXXVII 

ANAESTHETICS FOR CHILDREN 
By Alex. Wilson, Esq. F.R.C.S. 

SENIOR ADMINISTRATOR OF ANAESTHETICS TO THE MANCHESTER ROYAL INFIRMARY, ETC. 

As regards anaesthetics, children come under much the same rules as adults ; 
they are in general better subjects, in the sense that they are Jess often the 
victims of those degenerative changes which in adults complicate the ad- 
ministration of anaesthetics. On the other hand, as they respond so readily 
to the action of anaesthetic agents they always require cautious handling. In 
addition to their greater freedom from degenerative changes, children from 
the anaesthetist's point of view differ from adults in certain particulars. Chief 
amongst these is their capacity for inhaling an anaesthetic. Children possess 
highly expansile chests, with a proportionately large lung area ; in propor- 
tion to their weight they probably have greater ' vital capacities ' than most 
adults, at least than those who lead sedentary lives. They have more 
available active lung space to absorb the anaesthetic. As a consequence of 
this relatively large vital capacity they can readily take in and absorb a large 
dose of any anaesthetic vapour, which explains the quickness with which they 
become insensible. We have seen a struggling child reduced to an almost 
lifeless condition by one deep inspiration of a concentrated chloroform 
vapour. Again, the crying and struggling often attending their taking of 
the anaesthetic make the inhalation of it jerky and irregular and more diffi- 
cult to regulate. 

The highly developed condition of the reflexes of children constitutes 
another difference in their behaviour under an anaesthetic. Thus they will 
exhibit movements during an operation, while an adult under similar con- 
ditions and in the same degree of narcosis would remain quiet. A child, 
though moving immediately before the termination of an operation, will 
often be long before it regains consciousness after the operation, though 
little or no more anaesthetic has been given. In the same way, the reflex 
for the act of crying is well developed in children, so that during an opera- 
tion they will often give a cry at a stage of narcosis in which an adult would 
either exhibit no sign of feeling at all, or merely move slightly. They do not 
necessarily perceive or remember the painful sensation. For example : 
occasionally a child will emerge shrieking from the narcosis o\ nitrous oxide 
and yet not have any painful impression, or the slightest idea why it is crying. 



764 AncestJietics for Children 

This readiness with which children cry has led to the belief that they ' come 
out ' of chloroform quicker than adults. 

The reflex spasm of the glottis from the irritation of an operation, often 
well seen in adults when the sphincter ani is dilated, is readily produced in 
children, even when they are well ' under.' It is most frequent in operations 
involving the urinary organs and anus, and while the bladder is being dis- 
tended, and is occasionally so great as to interfere with respiration. It is 
relieved, but not entirely removed, by extending the neck, pushing forwards 
the lower jaw, and by giving more of the anaesthetic. It is very rarely 
necessary to pull out the tongue with forceps. 

Children are very susceptible to shock, and no suddenly painful procedure 
•(e.g. wrenching a joint) should be undertaken when they are in a semi- 
anaesthetic state. Though the occurrence of reflex paralysis of the heart 
lias been denied by certain recent observers (Hyderabad Chloroform Com- 
mission), we have seen one case (a young girl) in which death was clearly 
•due to shock produced by flexing a limb when the patient was not completely 
under the influence of the anaesthetic. 

local Anaesthesia for exploratory punctures may be produced by holding 
a piece of ice dipped in salt against the surface until it is frozen, or by the 
ether spray or by ethyl chloride. 

Cocaine, from the method of applying it, from its irregular action and 
the unpleasant symptoms it sometimes causes, cannot be much used for 
•children. 

Nitrous Oxide is well borne by older children and may be always used 
in dental operations. It might be employed with advantage in many minor 
operations, as its transitory effects can be made more prolonged by repeated 
administration, when free access to the mouth is obtainable, or the admixture 
of ether with the gas may be used. Children go quickly under the influence 
of nitrous oxide, and the period of anaesthesia is shorter than it is in adults ; 
they also exhibit a greater degree of spasm, opisthotonos often being well 
marked — a point to be remembered, as it may be a disturbing element. The 
combination of oxygen with nitrous oxide is especially useful in children ; it 
greatly diminishes the spasm and unsteadiness, and slightly prolongs the 
anaesthesia. The same effects can as conveniently be produced by giving a 
little ether with the gas. 

Chloroform, in the case of children, is not quite the safe and desirable 
anaesthetic it is often represented to be. Altogether, a fair number of deaths 
from it have been recorded, and many more unpleasant, though non-fatal, 
accidents have occurred with it. Children possess no special powers of 
resistance against the lethal action of chloroform or any other anaesthetics. 
The youth of the patient is a source of safety only, because it implies a greater 
freedom from disturbing degenerative changes in the nervous, circulatory, 
and respiratory systems. With chloroform it is very easy for the patient to 
take an over-dose ; it generally causes some cardiac depression, which may 
be of an alarming character, shown by pallor and lividity of the face, and 
feeble pulse— frequently before the operation has been commenced. The 
after-sickness sometimes continues a long time. As a rule, the sickness and 
faintness at the end of the administration are greater in children than in 
adults. Even after a trivial operation there may be to an unpleasant degree 



Ether 765. 

a feeble pulse, cold clammy skin, &c, so much so that this has led certain 
surgeons to employ ether as the routine anaesthetic for children and chloro- 
form for adults. Chloroform is contra-indicated in operations for spina 
bifida and hydrocephalus (Morton). It is recommended by Horsley in 
cerebral surgery ; the administration to be preceded by a hypodermic injec- 
tion of morphia. 

Ether compared with chloroform is less depressing : the pulse continues 
strong throughout ; the face keeps a good colour ; the endency to syncope 
is diminished, and the after-sickness is of shorter duration, often ceasing 
when once the stomach is emptied of mucus. It is quicker in its action 
consistent with safety, so that the distressing struggles of a child can be 
speedily ended without danger, in a way that could not be done with chloro- 
form. The risk of suddenly giving an over-dose is almost nil. Ether, 
however, has disadvantages ; it requires some apparatus for its proper 
administration, it occasionally causes considerable secretion of mucus, and 
when given alone it is unpleasant. The last of these objections can be over- 
come by giving it in combination with nitrous oxide, or by first giving a little 
chloroform. The secretion of mucus in children is no greater than it is in 
adults, and only in the minority of cases is it enough to give any trouble. 
When it is excessive it may readily block up the small trachea and bronchial 
tubes and give rise to inconvenience, especially if the patient is kept deeply 
narcotised. In these cases changing the anaesthetic to chloroform does not 
immediately improve matters, as the change does not remove the mucus. It 
is better to allow the patient to recover consciousness enough to clear the 
lungs by coughing. Ether is contra-indicated in lung disease, and is sup- 
posed to be dangerous in kidney diseases. 

The A.C.E. mixture is a weaker anaesthetic and not as depressing as- 
chloroform, and so safer ; but it is not as safe as ether. 

Bichloride of Methyl presents no special advantages over the above- 
mentioned agents. 

The Choice of an Anaesthetic. —On this point too much stress must 
not be laid upon the mere question of age ; extreme youth does not neces- 
sarily contra-indicate the exhibition of ether, nor make imperative the use of 
chloroform. Though inhalers are not made to fit infants, if considered 
necessary, ether can be given on lint, or the narcosis produced by chloroform 
can be kept up by ether. Roughly speaking, chloroform is best for children 
under five years ; it is also the handiest anaesthetic for older children ; but 
ether is certainly the safer. For those who desire to employ an agent 
between the two in lethal capacity the A.C.E. mixture presents itself as a 
convenient medium. If it is thought advisable during narcosis to change 
from ether to chloroform, care must be taken that an over-dose be not given, 
as the deep respiration and full pulse produced by ether make very easy the 
inhalation of a fatal dose of chloroform. This fact, long ago proved by 
clinical experience, has been recently well illustrated by the experiments oi 
the Hyderabad Chloroform Commission. 

Preparation. — If possible, an anaesthetic should not be given within 
three or four hours of a meal. As children bear badly the deprivation o( 
food, any longer interval, besides being unnecessary, is injurious, making 
the patient feel faint. A feeble child, or one kept long without \\\\), 



j66 Ancestlistics for Children 

should be given some liquid nourishment, some little time before opera- 
tion. 

In every case it is well to have at hand chloroform, ether, and A.C.E. 
mixture ; the administrator should also have a plentiful supply of lint, tongue 
forceps, a hypodermic syringe, nitrite of amyl capsules, sponges and an 
electric battery, and a mouth-gag with a sponge-holder. These latter are 
occasionally required in cases of vomiting. 

Before beginning the administration, examine the mouth for any loose 
temporary teeth which might become detached, especially if a gag is to be 
used, and also in better-class children for any dental regulating plates ; avoid, 
if possible, alarming the patient, for with a struggling, crying child the 
danger of giving an over-dose is increased. By a little tact most children 
can be anaesthetised without any crying, even when inhalers are used. If 
the child is nervous, let it sit on its mothers or nurse's knee. If it is not 
undressed, don't have it undressed until it is 'under,' then it can be done 
without alarming it. Let it see the inhaler or lint, and smell it before any 
anaesthetic is put on. During the administration, when the smell is objected 
to, incite the patient to ' blow it away.' It is not absolutely necessary that 
the child should be lying down in the early stages ; if quiet can be gained by 
letting it sit up, let it do so. These small details are of importance, as there 
is no doubt that to a highly sensitive child the struggling and shock of being 
choked off by an anaesthetic may have injurious after-effects. Should the 
child cry, go on steadily with the administration, but do not give an extra 
quantity or ' push ' the anaesthetic to get it ' under ' the quicker. As it is 
breathing more deeply than normal, rather put less of the anaesthetic in 
its way, and so avoid all chance of the sudden inhalation of an excessive 
dose. 

Ether is best given with a Clovers inhaler ; it should be administered 
slowly ; if the child struggles and becomes unmanageable, it is allowable to 
turn it on to ' full ' and get it under quickly. In giving gas and ether, 
Hewitt's modification of Clovers inhaler is the most convenient. Very little 
gas is required, and the ether should be turned on before any spasm sets in. 
When the patient is once ' under,' only a small amount of ether is needed to 
keep up narcosis ; a strong ether vapour causes an unpleasant amount of 
mucus to be secreted. 

Chloroform is most conveniently given on lint. First put a little vaseline 
on the face to prevent blistering ; place the fold of lint over the nose and 
mouth and then gradually drop the chloroform on it ; when the patient ob- 
jects, coax him to ' blow it away.' 

It is a good plan, standing on the patient's right, to hold the lint on the 
nose with the left thumb and forefinger, pressing on the nasal bones, while 
the third and fourth fingers spread over the forehead, feel the pulse of the 
anterior temporal artery, and steady the head ; the right hand is then free 
to drop on the chloroform and control any movements. In dropping the 
chloroform hold the bottle near the lint ; if it is dropped from a distance, it 
is extremely easy for a little to get into the eye. 

Hold the child as little as possible. If it seizes the lint, quickly replace it 
with a fresh piece rather than waste time struggling for the first ; never try 
with chloroform to ' send it over quickly.' Each inspiration means one dose 



Vomiting j6j 

of the drug, which takes effect some seconds after its inhalation, therefore 
remove the lint at the first sign of anaesthesia, or the patient will get several 
unnecessary doses. The quickness with which children become unconscious 
has been referred to. Should there be coughing, in the deep inspiration 
following the cough, do not let the patient inhale too much chloroform vapour, 
and be careful not to mistake the general jerking of the limbs caused by the 
coughing for voluntary movements requiring more chloroform. It is oc- 
casionally difficult to entirely abolish reflex movements during an operation 
on the skin, and the anaesthetist must therefore not respond too readily to 
the ' More chloroform, please,' of the operator. 

Spasm of the glottis with crowing inspiration is very common, especially 
if the patient is not quite ' under,' or is beginning to have nausea ; it is 
generally a sign of imperfect anaesthesia, and when accompanied by such 
signs as rigidity of the jaw muscles, contracted or slightly dilated pupils, and 
a good pulse, is an indication for more of the anaesthetic ; the spasm is partly 
relieved by pushing forwards the jaw with the neck hyper-extended ; as 
previously remarked, pulling out the tongue with forceps does not remove 
the spasm, it is rarely necessary, and should be avoided as much as possible, 
as being liable to cause unnecessary after-pain in the shape of a sore tongue. 
If it is considered advisable to keep the tongue drawn out, it should be gently 
held out with a pair of tongue forceps, or, better still, by the fingers and a 
piece of lint. The lower jaw can be conveniently held forwards by using 
the closed forceps as a lever, the upper teeth acting as the fulcrum. 

During the administration the same rules should be observed with chil- 
dren as with adults. 

Vomiting-, if the stomach is empty, can be overcome by giving more 
chloroform, otherwise it is better to suspend the administration until the 
stomach has been emptied, and then to resume it ; turn the patient well on 
one side during vomiting, and keep the mouth and pharynx clear. A patient 
with a loaded stomach will breathe badly, have stertor, and present a more 
or less cyanotic appearance. Frequently the vomiting will be preceded for 
some time by a condition in which the patient presents a feeble pulse, 
irregular, stertorous, or spasmodic respirations, and more or less cyanosis, 
which is improved when once actual vomiting begins. The corneal reflex is 
an uncertain index of the state of general anaesthesia ; it may be absent from 
one eye while it is present in the other ; it will often be present throughout an 
operation while the patient presents no other indication of sensation, and it 
may be absent in both eyes and yet the patient will vigorously indicate that 
sensibility to operation is present. In the latter condition it has been sug- 
gested that the chloroform vapour exerts a local anaesthetic influence on the 
conjunctiva. A good deal depends upon the painfulness of the operation ; 
therefore, as a test of the sensibility or degree of narcosis, the corneal reflex 
must be considered in conjunction with other symptoms and conditions. 
Thus, the corneal reflex being absent in both eyes, a deficient degree o\ 
anaesthesia (narcosis) will be indicated by some or all of the following sym- 
ptoms, which serve to check the inferences derivable from the cornea, viz. 
contracted pupils, slight movements of the lips, modification of the facial 
expression, rigidity of the massetcrs, alteration in the rhythm of the respira- 
tions or increased rapidity or spasm of the glottis, and movements, chiefly 



y6S ' Anesthetics for Children 

extension of the fingers or occasionally momentary dilatation of the pupils 
when a sudden pain is felt. 

The condition of the pupil taken by itself is also not of much help as an 
indication of the stage of anaesthesia. It generally dilates to a varying ex- 
tent during the first stage, widely if there is struggling ; it may remain widely 
dilated throughout the administration, even though the narcosis is not deep,, 
and the corneal reflex may be present with a widely dilated pupil. 

Generally the dilatation gives place to moderate contraction after the 
operation has been commenced. The onset of sickness is accompanied with 
a dilated pupil, and shock causes wide dilatation of the pupils. In testing- 
the corneal reflex do not hold the eyelid up in a way that prevents it closing,, 
as is occasionally done. Should there be a return to consciousness during an 
operation, the administrator must be careful not to ' push ' the anaesthetic too 
freely, and must not go straight on giving the anaesthetic until the patient is 
quite quiet again, but must watch the effect of each dose (i.e. inspiration). 
The enfeebled condition of the patient at this stage and the irregularity of the 
respirations, which are generally deeper and quicker than normal, make it 
an easy matter to give an over-dose. There are several fatal cases on record 
which prove the need for caution under such circumstances. 

When once the child is ' under ' it is very important to avoid moving it 
suddenly or roughly ; such treatment tends to cause syncope. This caution 
is especially necessary if there has been any loss of blood or there is faint- 
ness. Under these circumstances never allow a patient to be raised up into 
a sitting or semi-sitting position for the putting on of dressings. This can 
easily be avoided by drawing the patient to the end of the table and 
supporting the body so that the head and shoulders project beyond the table r 
full access can thus be gained to any part without in the least raising the 
patient. We have seen a serious attack of faintness brought on by the 
sudden raising of the head and shoulders of a child at the end of an operation 
in which a considerable amount of blood had been lost. 

In connection with this it is important to remember that feeble respirations 
are not always associated with shock. One of the most serious symptoms 
of cardiac and general failure is deep gasping respiration accompanied with 
a quick running pulse. If, in a patient undergoing a severe operation, 
ordinary quiet respiration suddenly gives place to deep inspirations, especially 
if they are of a gasping character, associated with a quick pulse and dilated 
pupil, it is a sign of serious if not fatal syncope. This is not as common in 
children as in adults, but it occurs in them under similar conditions. It is 
due to anaemia of the respiratory centre, whether caused by actual loss of 
blood or cardiac failure. 

Anaesthetics in Special Operations.- — There are practically no con- 
ditions under which an anaesthetic is contra-indicated ; if an operation can 
be performed, an anaesthetic can be given. A few operations require special 
notice. 

In Tracheotomy an anaesthetic, though not absolutely necessary, is a 
distinct advantage, especially where it is desired to clear membrane from 
the trachea. The danger that it might set up fatal spasm can be avoided 
by giving it gradually in a diluted state and by delaying the administration 
until the operator is quite ready. As preparation for any emergency, it is 



Operations on the Mouth j6q 

well to arrange the patient on a definite plan, e.g. on the back, with the 
shoulders and back of the neck supported by one firm pillow and a second 
smaller one under the occiput. In the event of a sudden spasm and cessation 
of respiration demanding immediate operation, by pulling away the second 
pillow the head at once drops backwards, making prominent the trachea 
without any lifting of the patient. This plan, though most useful in dealing 
with heavy adults, is equally valuable in children. 

Operations on the Mouth. — In all operations on the mouth or pharynx 
it adds materially to the chloroformist's comfort, and to the patient's safety, 
to have the patient's head hanging downwards ; either hanging over the end 
of the table, or with the neck so extended over pillows that the vertex of the 
head rests on the table. This position keeps the larynx quite free from blood 
which, while it is fluid, will escape through the nostrils. A damp towel or 
bathing cap should be fixed around the head to keep the hair from being 
soiled. 

As regards anaesthetics, the fact that the operation is one involving the 
mouth or throat does not in itself confine the anaesthetic to chloroform. Mr. 
Warrington Haward has shown that ether may be used in the operation for 
cleft palate, and we are constantly in the habit of giving ether in post-nasal 
adenoid growths. 

In cleft palate, chloroform is the most convenient anaesthetic ; it should 
be given on lint until the patient is ' under,' and then the administration con- 
tinued by Junker's inhaler ; by which means the operator can work con- 
tinuously without being interrupted by the chloroformist. 

In the operation for post-nasal adenoid growths, an anaesthetic (gas and 
ether or chloroform) should always be given. The patients are longer in 
going 'under' from the interference of the adenoids with respiration, but that 
is all. If the head is allowed to hang downwards, the free haemorrhage is 
never any real trouble. In laryngoscopic examinations, chloroform is useful 
for abolishing the fear of the patient ; but it will not always cause sufficient 
anaesthesia to permit of the larynx being manipulated through the mouth. 
In one case of laryngeal polypus in a child aged six years, under the care of 
Dr. Harris, we utterly failed to produce anaesthesia sufficiently deep to per- 
mit the polypus to be removed by the mouth, even by combining the cocaine 
spray with the chloroform. 

In empyema cases chloroform is best. Care must be taken not to produce 
coughing by giving it too strongly at first, and the child must not be turned 
to the sound side. 

In cases of trephining the spine, chloroform should be given. The best 
plan, especially if there is paralysis of the intercostals, is to turn the patient 
right on to the face and support the body on pillows in the following way : 
the anterior iliac spines rest on a firm sand pillow, an ordinary thin pillow 
supports the chest, and the forehead rests on a small firm sand pillow. By 
this means the operator gets free access to the spine, the abdomen is not 
pressed upon and the diaphragm has full play, while the mouth and nose 
are supported some distance from the table, and the chloroform lint can be 
slipped under the nose as required ; any secretion flows easily out of the 
mouth. 

Operations on the Bladder. — In these cases it is important to have the 

\ D 



770 Ancesthetics for Child}'en 

patient ' under' before injecting the bladder is begun. If this is neglected, 
the manipulations will most likely set up spasm of the glottis and straining, 
which will impede the inhalation of the anaesthetic and delay the production 
of anaesthesia. 

Accidents are of a similar nature to those which occur in adults, and 
should be treated on similar principles. As examples of the various kinds of 
accidents, may be quoted cases in which an attempt is made to speedily 
anaesthetise a crying child, with the result that it is allowed to take several 
deep inspirations of a highly concentrated chloroform vapour, and so obtains 
a sudden over-dose ; in other cases where it is desired to produce deep 
anaesthesia the dangerous symptoms may be initiated by some sudden move- 
ment of the child when it is deeply under. We have seen two cases of this 
class when the patient was deeply narcotised for the operation of cleft palate ; 
the sudden raising of the patient produced symptoms of syncope. In un- 
prepared patients the embarrassment of respiration caused by a loaded 
stomach and the onset of vomiting gives much trouble. The patient 
breathes with difficulty, has spasm of the glottis, becomes pale and slightly 
cyanosed, has a feeble pulse, etc. ; most of these symptoms are relieved by 
vomiting. 

In the treatment of accidents it is well to remember that heat is a power- 
ful cardiac stimulant, and a hot sponge placed over the heart is better than 
slapping the chest with a wet towel. When the windows are thrown open in 
a case of shock, care must be taken to keep the patient covered and warm. 
Artificial respiration must be done quietly and efficiently. Intermittent 
pressure over the heart, as recommended by Schmeidberg, is useful in cardiac 
failure, and inhalation of nitrite of amyl in cases of engorgement of the right 
side of the heart. 

The battery is useful only as an aid to artificial respiration, by faradising 
the phrenics. Unless this can be effectively done it had better be left alone 
and reliance placed upon ordinary artificial respiration. In cases of shock 
after long operations, inhalations of oxygen are highly recommended. Of 
this we have had no experience. 

Subcutaneous injections of ether, though they are strongly condemned 
by certain authorities, in some cases do seem to do good. Of course, if the 
patient has been taking and is already saturated with ether, it would be use- 
less to give more. 



APPENDIX 



DIPHTHERIA. 

Serum-therapy — Antitoxin treatment of diphtheria. — The attitude of the 
American profession at the latest moment of issuing of this edition justifies a 
stronger statement of the value of the antitoxin treatment. The following is 
extracted from a recent article summarizing the present status of diphtheria anti- 
toxin treatment, by Prof. W. H. Welch.* Antitoxin acts through the agency of the 
living body, rendering the cells tolerant of the toxin. The cells must therefore be 
in a condition to respond in the proper way to the introduction of the antitoxic serum. 
The toxins of the diphtheria bacillus are most powerful poisoners of cells ; the result 
being cell death. There is no way of determining by hours the extent of damage 
the cells may have already sustained. There is some evidence in favor of the 
view that while antitoxin may exert its protective action upon certain groups of 
cells, other cells, as for example the nerve-cells, may either by their nature or on 
account of certain influences, not be wholly protected against the toxin. Paralysis 
(post diphtheritic) may occur in cases treated with serum, where early treatment 
has been practiced and with favorable results upon the faucial dipththeria. 

"If the benefits of antitoxin are unmistakably manifested in these operated 
cases of croup then the test is an experimentuni crt/cis." In comparing reports of 
previous or simultaneous fatalities from tracheotomy, taking the lowest figures, 
there was an apparent reduction of 34.1 per cent, by the serum treatment, and 
from intubation an apparent reduction of 40,. 5 per cent, from serum treatment. 
Finally, the fatality of 3,127 non-operated cases was only 11. 4 per cent, with the 
serum treatment. 

" In twenty-four to forty-eight hours after the injection the general condition 
of the patient is remarkably improved in the great majority of those patients who 
are in a condition to be benefited at all by antitoxin. The general improvement 
is accompanied by a fall of temperature, which may be a critical fall, especially if 
the disease is not far advanced ; often it is by lysis. . . . Accompanying the 
fall of temperature is improvement of the pulse as to frequency and tension, but 
the heart's action may for some time, even into the period of convalescence. 
remain weak. In the favorable cases the local diphtheritic process i> arrested. 

* Transactions of The Association of American Physicians, also " Bulletin of The Johns 
Hopkins Hospital," July August, 1895, also reprint, etc. 



772 Diseases of Children 

usually within the first twenty-four hours after the injection. . . . The area 
covered by membrane becomes sharply demarcated, and the swelling of adjacent 
mucous membrane disappears. . . . Nasal discharge is lessened. The swelling 
of the glands in the neck and the surrounding oedema disappear, so far as these 
are not referable to secondary infections." 

" The principal conclusion which I [Dr. Welch] would draw from this paper is 
that our study of the results of the treatment of over 7,000 cases of diphtheria by 
antitoxin demonstrates beyond all reasonable doubt that anti-diphtheritic serum is a 
specific curative agent for diphtheria, surpassing in its efficacy all other known 
methods of treatment for the disease. It is the duty of the physician to use it." 

The antitoxin serum should be secured from a reliable source, should be clear, 
sterile, and strong in antitoxin. It should be kept in a cool place. 

The dose in a given case should be estimated primarily by the extent of the 
local lesion and severity of the constitutional disturbance, secondarily by the size 
of the patient and the stage of the disease. In a young child, with a small exu- 
date upon the tonsil and the parts immediately adjacent, a single dose of 800 c. c. 
Behring's standard No. 2 solution, or 15 c. c. of a 1 to 50,000 solution Roux, may 
be sufficient. For older children and adults 1,000 units is a proper dose. In 
cases of pronounced severity, or where toxic effects are already present, or where 
the diphtheritic process has invaded the larynx, a full dose of 1,500 to 2,000 units, 
10 to 14 c. c No. 3, should be unhesitatingly administered. If improvement in 
the symptoms is not observed on the following day, 1,000 to 1,500 units should be 
given. Occasionally a third injection is necessary. If, as occasionally happens, 
after a few days a moderate amount of diphtheritic exudate reappears in the phar- 
ynx another injection is indicated. 

For injecting the antitoxin serum a large hypodermic syringe, holding from 10 
to 20 c. c. is usually employed. Special syringes are made for this particular use. 
Their main recommendations are that their size is sufficient to hold the maximum 
dose, the packing is of such material, notably asbestos, various compositions, or 
removable rubber, as to allow either of boiling the whole instrument without 
removing the piston or of easily removing and freely washing both piston and 
packing.- The usual precautions as to syringe and skin that hold in ordinary 
hypodermic injections, are considered safe. The injections should be made into 
the loose subcutaneous tissue, not into the muscles, the usual site being a short 
distance below the nipples on one or both sides according to the size of dose ad- 
ministered. The skin immediately after an injection usually bulges forward, 
forming a prominent swelling, but the serum is quickly absorbed and it is better 
not to employ massage to facilitate its absorption. A strong needle, rather long, 
not too large, is best for the purpose. As a rule there is but little pain following 
an injection, though there is occasionally some tenderness for a few days. With 
proper serum and ordinary precautions no abscesses should follow. 

Cleansing; the Throat. — All other rational methods of treatment of diphtheria 
should be added to that of antitoxin — cleansing the throat especially. 

In the condition of sloughing, foul-smelling tonsillar and faucial diphtheria, per- 
oxide of hydrogen (" fifteen volume ""whole strength or diluted with equal quantity 
of lime-water) serves a useful purpose. For moderate cases it is to be recommended 



Appendix 773 

with great caution, for too energetic treatment may easily cause injury to the healthy 
mucous membrane, as pointed out by Jacobi. 

Another very good method is the following: Syringe the throat first with pure 
water, to accustom the child to the practice, delivering a gentle douche which will 
flow readily from the mouth. Next, depress the tongue gently and syringe again 
till the child has learned its role. Gradually the force may be increased until a 
sharp jet is thrown well back into the throat, any desired medicament being added 
to the water. 

A hard-rubber piston-syringe of four drachms capacity or more, capable of being 
easily managed with one hand, is best. The nozzle should be short, passing just 
within the teeth, so as to avoid injury to the parts. In young infants this method 
serves well, and if carefully used allows none of the fluid to be swallowed. After 
the throat is well cleansed corrosive sublimate solution, one part to 5,000 up to one 
part to 2,000, may be used, this being the most efficient disinfectant. These are 
to be preferred to all other methods of throat cleaning and disinfection. It is desir- 
able not to use corrosive sublimate in such strength as will cause marked irritation 
lasting more than a minute. 

Intubation.* — The views expressed on page 207 are not so favorable as those 
prevailing in America, Germany, France, and Hungary. Intubation is capable, in 
the hands of a skilled operator, supplied with the proper sizes and shapes of tubes, 
of meeting all emergencies which the advocates of tracheotomy claim for the cut- 
ting operation. This was true even before the adoption of the antitoxin treatment 
of diphtheria. The points to be specially considered are : 

When to operate. 

How " 

How to remove the tube. 

When 

Dangers and difficulties of operation, 
wearing, 
removal and thereafter. 

Advantages. 
When to Operate. — When a progressive, unremitting dyspnoea, despite all pre- 
vious treatment, allows any considerable part of the posterior portion of the lungs 
to become non-inflated, when the labored breathing begins to produce sensible 
exhaustion, intubation is to be performed promptly. 

How to Operate. — Wind the child from chin down in a light blanket, shoulders, 
arms, and hands included. Tin the blanket closely about the neck, and yet do not 
make a bulky roll to interfere with depressing the introducer handle. In this way 
the elbows are pinioned to the side and the hands are held across the child's abdo- 
men. 

The nurse sitting upright, not leaning back, should grasp the child's elbows 
firmly, outside its winding blanket, of course, and clasp the child's legs between 
her knees, making sure she twines her own about the legs of the child. Some 
prefer to stand the child upon (he nurse's lap, she (the nurse) clasping her arms 

* Extracts from a p:\per read by the American Editor, before the British Medieal Assotia- 
tion, Bristol, England, 1804, and published in Brit. Med. Journal^ Dee. 39, i^> 4 . 



774 Diseases of Children 

about its knees. All these precautions are to secure the child in a firm grasp, to 
immobilize it without interfering with the expansion of its chest, and may be taken 
without causing any apprehension or excitement. The position of the child should 
be as though it hung from the top of its head. 

The physician assisting should stand behind the chair of the nurse, grasp the 
child's head between his hands, hold it firmly, and when the gag has been inserted 
include it within his grasp to insure its firmness and steadiness. The operator, 
seated or standing squarely facing the child and nurse, inserts the gag, opens the 
mouth widely, and gives the handle into the keeping of the assistant. The intro- 
ducer, armed with the proper-sized tube, is supposed to be threaded and at hand. 

Next he inserts his index-finger, hooks up the epiglottis, crowds his finger to 
one side, passes the tube past it till it engages in the chink of the glottis, elevates 
the handle, gently passes the tube down till the head is within the box of the lar- 
ynx and the introducer lies crowded upon the tongue. He then, with the trigger, 
loosens the obturator, holds the tube with the left index-finger while withdrawing 
the obturator, and with a gentle thinist presses the tube's head well into the larynx 
and removes the finger and gag. Just here let me emphasize what is stated above 
— keep the introducer in the middle line ; otherwise the obturator will pinch in the 
calibre of the tube and drag the tube with it as it is withdrawn. 

The handle of the introducer should be held most lightly between the end of 
the thumb and the fingers. In this way it is impossible to use enough force to 
make a false passage. The lines and angles must be maintained to insure quick 
intubation. If on the first attempt the tube is not successfully placed in the lar- 
ynx it is better to make repeated short attempts than prolong one. 

Having placed the tube in the larynx, there will be rattling in the tube on first 
respiration and subsequent cough and expectoration. A vigorous cough argues 
well for the sensitiveness of the parts, and for evacuation of accumulations below. 
The gag is removed as soon as the tube is in place, but not so the thread ; it must 
remain till it becomes evident that all obstruction to breathing has been overcome, 
and no partially detached false membrane is in the trachea below the tube. The 
thread at first acts as an inciter to cough, which is desired ; ordinarily, ten minutes 
are sufficient time. 

How to Remove the Tube. — Place the child in the position for intubation as 
described above. Thrust the left index-finger past the epiglottis, hook it up, rest the 
tip of the finger upon the two arytenoid cartilages and carry the extractor point to 
the end of the left index-finger at the pulpy portion generally regarded the most 
delicately tactile. The situation is then as follows : — The finger-tip upon the 
arytenoid marks the posterior boundary of the glottis in the median line. Now, 
if the extractor point be carried along the median line to the end of the finger and 
the handle be elevated, the point will naturally be pried foward from the end 
of the left index-finger on the arytenoids, into the aperture of the tube. Occasion- 
ally cases are found in which the epiglottis hugs so closely the head of the tube 
that it is very difficult to raise it and keep it out of the way. This is liable to 
occur, especially in ascending croup, in which the epiglottis is not always involved 
in the diphtheritic process. In such cases the extractor would be guided better 
with the left index-finger at the side, as in intubation. The guard screw of the 



Appendix 775 

extractor-lever should be carefully set to avoid injury to the tissues in case the 
extractor jaws should be opened by mistake in the soft parts instead of in the 
tube. Many operators, both in Germany and America, leave the thread attached 
throughout the whole time, and occasionally a tube is coughed out after the swell- 
ing releases its grip. So in actual experience one is not called upon to extract 
so often as to intubate. The fact remains that extubation is more difficult. 

When to Remove the Tube. — This depends on the age of the child and duration 
of the disease before intubation became necessary. The older the chdd the earlier 
the tube can be dispensed with. Estimating the maximum of the disease to be 
seven days, five days' wearing the tube is considered, on an average, sufficient. 
The use of antitoxin has diminished the time of sojourn of the tube to forty-eight 
and often twenty-four hours. 

Dangers and Difficulties of the Operation. — In the hands of an experienced 
operator there are practically no dangers to life at the time of operation. 

A few authentic cases of pushing down membrane before the entering tube 
have been recorded. Expert intubation according to latest practices presupposes 
that the thread has been left attached, and therefore easy immediate removal is 
possible. This experience with loose pseudo-membranes occurs more often late in 
the disease, and in reintubations. 

To the inexperienced there are many dangers : (i) asphyxia from prolonged 
attempts ; (2) laceration of the parts, false passages, etc. The explanation 
usually given to those two most common accidents is "pushing down false mem- 
brane." So called syncopal attacks are simply lesser attacks of asphyxia. Con- 
vulsions are recorded, and instruments have been broken in intubation. 

An experienced operator may encounter two difficulties : 

1. The point of the tube may enter one of the ventricles of the larynx. This 
is not common, for the original disease usually fills and obliterates these cavities. 
Such obstruction, however, does occur. It may readily be seen how an inexpert, 
sure that his tube and handle were exactly in the middle line, might force his tube 
into the tissues of the neck. He certainly has but to remember the cardinal 
points of advice, and he will use most gentle pressure ; he need but look at the 
light introducing instruments to appreciate that they are for delicate work. 

2. The second difficulty or obstruction that an experienced operator may meet 
in intubation is subglottic stenosis — or what is so often described as "oedema." 
The narrowest part of the respiratory ways is the cricoid ring. This fact, so far 
as I know, came to light for the first time in Dr. O'Dwyer's early investigations 
in intubation. If the head of an intubation tube be forcibly crowded down from 
above, it may pass the vocal bands, and yet resist all effort at the cricoid ring. 
Given a resisting cartilaginous ring lined with mucous membrane, we have the 
very elective conditions for stenosis. Fortunately, the swelling and infiltration 
are not often extensive enough to cause serious obstruction, but may be. Opera- 
tors come upon cases where the properly selected tube surely passes into the 
larynx, and yet encounters resistance — even "creeps back," as someone savs, 
" like an oiled cork in a bottle." If one is sure of the diagnosis, and a proper 
size fails, a smaller tube may, with moderate pressure, be introduced. This is the 
only condition where force is justified in intubation. 



776 



Diseases of Children 



Dangers and Difficulties of Wearing. — I. The tube may become obstructed 
by loosened plaques of false membrane. This constitutes the one important 
danger in wearing an intubation tube. It is easy to understand that large plaques 

may become loosened and detached in the 
trachea, especially after several days of the 
disease. 

A detached plaque may act like a valve at 
the tube's lower end, closing on expiration, 
opening on inspiration till the lungs become 
quite distended from accumulated air. 

At this point let me interject the symptoms 
of loose membrane : — (i) croupy character of 
cough (tube being in) ; (2) flapping sound ; (3) 
most important, sudden obstruction to outgoing 
air, especially during coughing. 

Most continental operators loop the thread 
about the ear, protecting it along the cheek with 
rubber adhesive plaster, and leave it throughout 
the wearing of the tube. This is advisable out- 
side of hospitals, with beginners, and in case 
loosening pseudo-membrane is suspected in the 
trachea. Possibly mucus may gradually collect 
in the tube, of such a tenacious quality, espe- 
cially in mouth-breathers suffering from high 
temperature, that it becomes an embarrassment 
or even danger. 

Short Tubes {loose membrane or foreign-body 
tubes.) — They are short, hollow cylinders of 
large calibre — short enough not to push down 
the tracheal membrane, yet long enough to reach 
below the cricoid stenosis and large enough to 
permit masses to pass through them. 

Occasionally a long tube loosens the upper 
attachment of a tracheal cast and crumples it 
into a wad below the end of the tube. The 
usual result is, as would be expected, apneea. 
Immediate removal of the tube is commonly 
followed by either expulsion of the cast or other 
disposal of the mass in the comparatively large 
trachea. At this point, when the long tubes have failed to give relief, the short 
cylindrics become of temporary service. 

These tubes are of various sizes, seven in number. Since they have no reten- 
tion swell it is necessary to use the largest size possible, wedging it into the larynx, 
and for obvious reasons in the line of pressure, not leaving them more than a few- 
hours in place. They require a special introducer with long curve in order to carry 
the short tube well through the cricoid constriction before withdrawing the obturator. 




Fig. 189.— Short large calibre tubes 
(loose membrane or foreign-body 
tubes). 



Appendix 777 

In short, to allow the expulsion of loose membrane from the trachea, the largest 
possible hollow cylinder is passed through the narrowed larynx, allowed to remain 
for a little, and removed as soon as the resulting cough has expelled the foreign 
body requiring its insertion. 

2. Ulceration from too large a tube making pressure within the cricoid ring, 
and ulceration at the lower end of the tube. The former can be of a serious 
nature, destroying the cartilage ; the latter is superficial and of little import. Ul- 
ceration within the cricoid is due to improper size ; ulceration below to improper 
construction of tube. 

Properly constructed tubes are difficult to describe, more difficult to secure from 
a maker, even if a most faithful and conscientious servant. But one maker in 
this world has succeeded in making tubes that embody all the ideas of the 
inventor. 

Feeding an Intubated Patient. — There is one disadvantage after operation : 
feeding is difficult. The larynx is sore. Many times it is sorer because of the inex- 
perience of the operator. The less the larynx is bruised in intubation, the less the 
child will dread the clasp of the pharyngeal muscles in the act of deglutition. The 
fact remains that there is more or less difficulty in swallowing, both from pain and 
cough. The latter arises from fluids entering the trachea, though many patients 
acquire the accomplishment, and learn to swallow very well. The method of feed- 
ing adopted by Dr. Casselberry, of Chicago, has very much relieved the situation. 
The child is inclined, head down, so that it swallows up-hill, and any fluid that 
may get into the tube in the act of deglutition quickly gravitates out again. The 
directions are as follows : — Place the child across the nurse's lap, bend the head 
well down, and feed either with a spoon or through a nursing bottle. At first 
these patients object, but when they learn that by so doing they can swallow with- 
out coughing they give no further trouble. 

Medication can be continued after intubation as well as before. 

Danger of Removal and Thereafter. — If the tube is removed on the fifth day 
in a case having an average fair course, there is little or no danger. The operator 
should remain half an hour. If in this time there has been coughing and clearing 
of the throat and trachea and no loose pseudo-membrane remains, and no dyspnoea, 
there will be no sudden urgent necessity of rapid reintubation. Even yet it is 
deemed desirable to be within easy call for some hours. 

I once considered I had on an average four hours' leeway, but exceptionally 
prompt aid was needed sooner, and a few cases needed reintubation twelve and 
twenty-four hours afterwards. Whether, pressure removed, the mucous membrane 
becomes quickly congested, or whether muscular spasm sets in. or membrane 
reforms, I know not, but I have learned to respect the emergency of the first 
twelve hours after removal of the tube, especially if it be a premature removal. 

Retained Tubes {Laryngeal Can it he). — Rarely it is necessary to reinsert a tube 
many times. The child may get along half a day or two days and yet require the 
reintroduction. If the tube is not of proper anatomical conformity it may cause 
granulations about the head. To relieve this and cure the condition, a special 
tube has been devised, naving a prolonged or built-up head. (See Fig. 190. "> It 
rides above and causes pressure upon the granulations, with consequent absorption. 



778 



Diseases of Children 



Finally, not to recapitulate the literature of the subject, I may mention advan- 
tages. First of all, parents will consent. 

It is a bloodless operation ; no cutting, no anaesthetic, 
and this means much to the friends. It is quickly per- 
formed, requires no trained assistants or trained attend- 
ants (it is trained operators that are needed). The air 
inspired is warmed and moistened through natural pas- 
sages. Results are equal to or rather better than those 
of tracheotomy under similar circumstances, whether in 
hospital or outside. 

Finally, since the successful employment of antitoxin 
treatment for diphtheria the average duration of laryngeal 
stenosis has been so shortened that there seems no longer 
any ground for contention as to which is the preferable 
method of tiding past the urgent symptoms of dyspnoea. 
As Professor von Ranke, of Munich, proclaimed to the 
British medical profession in London, " the time has come 
when it should be upon a man's conscience to leave a 
scar upon a child's neck, for, with the employment of 
healing serum there remains no excuse for tracheotomy 
in diphtheria." 




Fig. 190.— Built-up head 
for granulations. 



GENERAL DISEASES. 

Scurvy. — The American cases, about 200 thus far reported, do not convey the 
conclusion that there is any necessary connection between rickets and scurvy. 
They are frequently associated, but in a majority of cases of scurvy there is no 
evidence of rickets. The first recorded case in American literature had a fatal 
ending and a complete autopsy. This case was under the observation of the 
writer ; the post-mortem studies and reports were by the writer, and it is his 
opinion that there was no evidences of rickets or syphilis present.* Furthermore, 
subsequent eases, and the reports of cases from different localities and by different 
observers, confirm the conclusion that scurvy has no necessary connection with 
rickets. 

Cases of rickets with associated scurvy have been cured of the scorbutic condi- 
tion and still remained unimproved rickets. 

Diagnosis. — If the mother announces that the child has rheumatism of the legs, 
and the physician discovers spongy gums, that case will pretty surely prove to be 
scurvy. 

Treatment. — Consists in correcting the regimen, fresh milk, orange juice, pro- 
tection of tender parts of the limbs. 

Progttosis. — Improvement follows in one week, recovery in three or four. 

Vulvo-vaginitis. — In summing up a series of investigations upon the cause of 
vulvo-vaginitis in children Dr. Henry Heiman, of New York, says :f 

* Transactions American Pediatric Society. M Scorbutus in Infants," Northrap, 1891 ; also 
N. Y. Medical Journal, May 26, 1894. Northrup & Crandall. 
+ N. Y. Medical Record, June 2, 1895. 



Appendix 779 

" The classifications hitherto offered for acceptance are, as a rule, mixed types." 
He proceeds then to conclusions from his own observations. 

" First, a catarrhal form, subdivided {a) into those due to uncleanness, foreign 
bodies and trauma ; (b) infections, but not gonorrhceal. 

"Second, (a) a gonorrhceal type due to gonococcus (Neisser) ; (b) the mixed 
infection due to gonorrhoea and possibly other diplococci." 

It would seem that gonorrhceal vulvo-vaginitis to American practitioners is of 
more frequent occurrence than to the English. At least recent literature has had 
it under more consideration. 

The test for gonococcus of Neisser is so practicable for the general practitioner 
that it deserves mention. Heiman says in his conclusions : "I believe the gono- 
coccus of Neisser is never present in the normal urethra as far as any experiments 
have shown. The diplococci found in the normal urethra can be positively 
differentiated by the Gram stain. Gram stain is the only crucial staining test for 
the presence of the gonococcus (Neisser), and should therefore be employed in all 
cases." The details of this well-known staining are a matter of general text-book 
instruction. 

Rickety Deformities (p. 409). — The transverse thoracic furrow, with the pro- 
jection of the ribs forming the lower edge of the thorax, so very common in severe 
cases of rickets, is often associated with more or less kyphosis of the dorso-lumbar 
spine. Sometimes there is a marked depression on one side or the other at the 
costo-sternal articulations of the three or four lower ribs. This deformity may or 
may not be due to rickets. All of these conditions can be very much improved by 
applying a light steel spinal brace to hold the spine erect and draw back the 
shoulders. Over this brace is applied a corset made of drill, which exerts pressure 
on the lower projecting ribs only, and limits abdominal respiration. Thoracic respi- 
ration is then developed by inspiratory exercises. The result will repay the sur- 
geon for the persistent work necessary, as the writer has seen in a number of cases. 

Curvature of the neck of the femur, Coxa Vera (p. 407). — A number of cases of 
this deformity have been recorded here already by Curtis, Whitman and others, and 
it seems likely that when more attention is directed to the condition our experience 
will be similar to that of Hofmeister and other German surgeons, who have found 
that the deformity is not very uncommon. It is produced by the weight of the 
body and diminished resistance in the bone. It is observed in two-thirds of 
the cases during childhood, and in the remaining third at the age of puberty. The 
affection starts with pain in the hip and limping ; at first in consequence of a long 
walk or great fatigue ; later, after a moderate walk ; ultimately no work is possible. 
Function is especially impaired in bilateral cases. The disease runs its course with 
periods of remission and exacerbation. In two or three years the pain ceases, and 
there remains as a final result an actual shortening of the limb, the great trochanter 
being above Nelaton's line. There is diminished abduction and inward rotation. 
The limb rests in a position of outward rotation, and the patient can produce 
exaggerated rotation in this direction. The walk is in consequence characteristic, 
and when the patient wants to assume a kneeling position he is obliged to cross 
his legs. The exact point of this incurvation is on the under side of the neck and 
a little posteriorly, which explains the elevation of the trochanter and the outward 



780 



Diseases of Children 



rotation of the limb.' A large number of so-called obscure cases of coxitis are 
really this affection. The diagnosis is important with reference to the question of 
early excision, sometimes recommended in hip disease. Rest will soon stop the 
pain. Then continuous extension, massage, and exercise may benefit some cases. 
The neck of the bone should certainly be relieved from the weight of the body by 
means of a hip-splint or axillary crutches, during the progressive stage. No 
promises should be made of diminishing the amount of curvature of the bone 
found when treatment is commenced. 

Schede has found this condition in rachitic children who have not begun to 
walk, and ascribes it in them to traction of the muscles attached to the trochanter. 

Shaffer (p. 409) favors supporting the kyphotic spine in severe cases of rickets 
during the progressive stage in order to secure bone-growth in the normal planes. 
In this way not only can we readily, and without discomfort, correct the evident 
kyphosis, but also correct or prevent the development of lateral curvature, since 
many cases of this curvature are dependent upon a rickety condition and develop 
very early in life. 

The splint most commonly used in New York for knock-knee and bow-legs is 
shown in Fig. 191. The jointed apparatus is efficient, since leverage is applied 
whenever weight is borne. It also favors muscular development, and allows a more 
graceful gait. A pelvic band may be added to control the position of the feet if 
required. These braces are somewhat expensive, but at the New York Orthopaedic 
Hospital this objection is met by allowing the patients to pay for them on the 
instalment plan. The Knight brace (Fig. 192) for bow-legs, and the Thomas 
knock-knee brace, are also largely used (see Fig. 79). These deformities can be 
more quickly corrected if, in addition to the application of the splints, the limbs 
be bent by manual pressure towards their normal position several times each day. 




Fig. 191.— New York Ortho- 
paedic Hospital Brace for 
Knock-knee and Bow-legs. 




Fig. 192. 



-Knight's Bow-leg 
Brace. 



Fig. 193.— Boston Children's 
Hospital Brace for Bow- 
legs. 



Appendix 78 1 

The pressure should be as great as the child will bear without crying, and should 
be maintained a minute or two, then relaxed and reapplied several times. In the 
very slight grades of deformity these forcible intermittent pressure-exercises may 
be sufficient to cure without the use of braces. 

In the Children's Hospital in Boston, the apparatus in common use for bow-legs 
(Fig. 193) is a light but rigid steel upright, jointed at the ankle, attached below to 
the sole-plate of the shoe. It runs up the inside of the limb nearly to the origin of 
the adductor muscles and is then bent forward and upward and curved to fit into 
the groin and come up as far as the posterior part of the dorsum of the ilium. 
Leather pads opposite the greatest convexity of the curve draw the limb over to the 
upright. For knock-knee a similar apparatus is used, but is applied on the outer 
side of the limb, and at the level of the trochanter the upright is bent backward 
and upward to lie against the upper part of the buttock. By fastening the upper 
ends together the position of the feet can be controlled. 

For extreme deformity powerful correcting apparatus have been devised by 
Shaffer {American Journal of Obstetrics, etc., vol. xiv., No. iii. ). 

Whether a case will require operative treatment depends more upon the flexibil- 
ity of the bones and the laxity of the ligaments than upon the age of the child or 
the amount of deformity. Anterior curvatures of the tibia have seemed to the 
writer the most intractable to mechanical treatment, and generally require an oper- 
ation for their correction (see also Bradford and Lovett, " Orthopaedic Surgery," 
p. 682). 

In America, Macewen's operation (p. 420) for genu-valgum is chiefly em- 
ployed. MacCormac's modification, in which the chisel is used upon the outer 
side of the limb and a green-stick fracture produced on the inner side, is also 
thought well of. In any case the practice is to wait until the active stage of the 
disease is past before operating. The saw is almost never used here. In general 
osteoclasis is not so much in favor as osteotomy. Rizzoli's or Grattan's osteoclasts 
are those most used. 

The ambulatory treatment of fractures and osteotomies as recommended by 
Bardeleben, Korsch, Albers, Krause, Dollinger, etc., has not as yet received 
enough attention in this country to report upon its usefulness. 

Lateral Curvature of the Spine. Early Onset (p. 421). — In a study of two 
hundred and twenty-nine cases, Ketch (New York Medical Record, April 24, 1SS6) 
found (1) that this curvature is principally a disease of childhood, and maybe either 
congenital or acquired ; (2) that puberty, except as a concomitant occurrence, which 
may by its attendant circumstances increase it or bring it into unusual prominence, 
has no direct causative influence ; (3) that lateral curvature should be looked for 
early in life, and as a factor in treatment the early inspection of children's spines 
becomes most important toward the prevention of the deformity. 

Bradford and Lovett also (" Orthopaedic Surgery," p. 106) recognize its appear- 
ance at an earlier age than is usually supposed. 

Treatment^. 424) .-—Shaffer relies largely in eases of rotary lateral curvature 
on an exercise partly active partly passive. Pressure is made by the operator's 
hand just under the greatest convexity, in a direction inward, forward, and up- 
ward, the opposite shoulder being elevated at the same time. The patient bends 



J%2 Diseases of Children 

over the hand exerting the pressure and untwists the spine as much as possible. 
The counter-pressure is exerted below by the weight of the pelvis and limbs, and 
above by the weight of the upper part of the thorax and head, increased, if neces- 
sary, by pressure from the operator's hand, which is being used to elevate the 
shoulder opposite the projecting ribs. In giving the exercise the patient swings 
obliquely forward and backward, and at every backward swing the pressure is ap- 
plied after the body passes the perpendicular. The patient is also encouraged to 
swing from rings hung at unequal heights, so as to overcorrect the drooping shoul- 
der. These exercises are given once, twice, or three times a day for from five to 
twenty minutes. Sayre (New York Medical Journal, November 17, 1888) advises 
the following movements, which are very similar to those of Bernard Roth ("Treat- 
ment of Lateral Curvature of the Spine," London, 1889) and are, with modifica- 
tions, those most generally used in the United States. The various exercises are 
repeated three times each at the commencement and later on a greater number of 
times. 

" The patient lies prone, the arms at right angles to the trunk, palms down, face 
turned to the convex side, and the back as straight as possible. The patient supi- 
nates the hands, throws the scapulae well back, raises the hands from the floor 
and lifts the trunk, while the surgeon holds the feet down. The breath should 
not be held during any of these exercises, but the patient should breathe naturally. 
If necessary to secure this, make them count out loud while exercising. 

With hands behind the head, the patient raises the elbows from the floor, and 
raises the trunk as before, the feet being held by the surgeon. 

With the hands behind the head and the elbows raised, the body is swayed to- 
ward the convex side, the patient trying to "pucker in" the bulging ribs and not 
to bend in the lumbar concavity. The feet are fixed as before. 

With the arm on the side of the convexity under the body, the other arm over 
the head, the heels fixed, the patient raises the trunk from the floor. 

Sometimes the arm on the side of the concavity is put on the opposite buttock, 
while the patient raises the trunk. Sometimes the arm on the convex side is 
put on the buttock, and in cases of marked lordosis, with great stooping of the 
shoulders, both hands are put on the buttocks while the patient raises the trunk. 

The patient now lies on the back, arms at the sides, palms up, and lifts first 
one foot in the air, while the surgeon makes resistance graduated to the patient's 
power ; repeated, say, five times. The same is done with the other foot, and then 
with both. The feet are next separated and then brought together once more while 
the surgeon resists. Each leg then describes a circle, first from within out, then 
from without in. 

If there is special weakness at the ankles, with a tendency to flat-foot, the pa- 
tient flexes the foot and extends it against resistance, and turns the sole of the foot 
toward its neighbor, the surgeon resisting, and it is then forcibly everted again by 
the surgeon, the patient resisting. 

The patient now lifts the arms from the sides, passing perpendicularly to the 
floor till they are stretched as far beyond the head as possible, and then, going at 
right angles to the trunk and parallel with the floor, returns them to the sides, 
palms up. 



Appendix 783 

While the heels are held, the patient rises to the sitting position, hands at the 
sides ; then she rises from the floor with the hands behind the head and the elbows 
at right angles to the trunk. 

The patient now stands with the heels together, toes turned slightly out, hands 
behind the head, elbows at right angles to the trunk : then rises on tip-toe, bends 
the knees and hips, keeping the back as straight and erect as possible, and rises up 
once more. With the arm on the concave side, high above the head, the arm on 
the convex side at right angles to the body, she rises on tip-toe, bends the hips, 
knees, and ankles so as to squat, then rises and stands. All this time care must be 
taken to push the body as straight as possible, and gradually educate the patient to 
hold it so without wiggling during these movements. 

Let the patient practise walking in these positions, both on the flat foot and 
tip-toe, and also step high as if walking up-stairs. With the palm of the patient's 
hand on the convex side against the ribs, pushing them in, the hand on the con- 
cave side, she pushes a slight weight up in the air, while the body swings so as to 
straighten out the curves. 

Sit behind the patient, fix her thighs with your knees, while she holds both arms 
above the head and bows toward the floor, keeping her knees stiff while you keep 
her ribs as straight as possible with your hands. 

With the arm on the concave side across the top of the head, and the arm on 
the convex side around in front of the abdomen, the patient bends to the convex 
side through the ribs, and not through the waist. 

The patient sitting with the back toward the surgeon, the latter pushes one 
hand against the most projecting part of the convexity, and, with the other hand 
passed under the shoulder of the concave side, straightens out the curve as much 
as possible, the hand on the "bulge" acting as a fulcrum in straightening the 
curve. 

The patient sits on a stool in front of the surgeon, who fixes the pelvis with his 
knees. The patient then twists the projecting shoulder to the front while the sur- 
geon holds the elbows, which are at right angles to the trunk, the hands being be- 
hind the head, and makes resistance. In the same position the patient swings for- 
ward and back, swinging through the hips, keeping the back stiff, and n^t bending 
in the waist. 

The patient pushes in the ribs on the convex side with the hand, and pushes up 
with the hand on the concave side, the same as when standing. She also lifts the 
arm on the concave side up at right angles with the body while holding a weight. 

In cases of round shoulders, windmill motions of both arms and to-and-fro 
movements of the head against resistance are advisable. 

The patient lies prone on the couch, all the body above the waist projecting 
from it, while the surgeon holds the heels. With the hands behind the head, the 
elbows thrown back, the body is bent toward the floor, then raised up ; later on, 
resistance is made by the surgeon. The patient lies on the concave side and 
rises up laterally. The patient lies with the convexity on the edge of the couch, and 
hangs off as far and as long as possible. 

One of the best exercises for removing the curve is for the patient to place the 
head in a collar attached to a cross-bar above the head, suspended from the ceiling 



784 Diseases of Children 

by a compound pulley and rope. The patient now grasps the rope as high up as 
possible, and pulls up hand over hand until the toes just touch the floor. While 
hanging thus she takes three deep, full, slow inspirations and expirations. While 
she is hanging thus the surgeon corrects the rotation by pushing the ribs with one 
hand while he steadies the pelvis with the other. 

Another good thing is for the patient to have a belt passing around the pelvis, 
with a handle at each side. Holding these in the hands, she straightens the arms 
out, and the spinal column is thus stretched and straightened much in the same 
way as by self-suspension. 

The patient stands bent forward as if playing leap-frog, her hands on a chair, 
while the surgeon, with one hand under the shoulder on the convex side and one 
hand on the projecting ribs, corrects the rotation. It is advisable to steady the 
patient with the knee while doing this." 

Teschner has lately (Annals Surg., Aug., 1895) advocated the system of exercises 
used by the German athlete Attilla. This consists of a long series of the usual 
light dumb-bell exercises with poising of the body in various positions. These 
are followed by swinging and raising at arms' length above the head very heavy 
dumb-bells and bars. The object being to thoroughly tire out the weak muscles, 
on the ground that in this way only can they be fully and rapidly developed. 

Rachilysis and other very forcible methods of reducing rotary lateral curvature 
have not found thus far much favor in this country. 

Apparatus for Lateral Curvature. — The supports used in the United States 
for lateral curvature are employed to retain an improved position and to relieve 
pain and weakness. Muscular development is at the same time encouraged in 
every way, the idea being to lay aside the apparatus as soon as the muscles have 
been made strong enough to retain the improved position. Some cases seen late 
in the disease cannot be improved in respect to deformity, and yet feel much more 
comfortable if properly supported. Others, again, from cardiac or pulmonary com- 
plications, cannot take the exercises required, and the ultimate results are better 
when mechanical treatment is carried out. In order that the appropriate exercises 
may be given all supports must be removable. Probably the plaster-of-Paris jacket 
applied with suspension is more generally used than any other method. Sayre 
moulds the patient's figure with his hands as much as possible after the jacket is 
applied and before it hardens. He uses the jacket as an adjuvant and only in 
those cases where the patient is not able to retain by voluntary effort so good a 
position of the body as can be obtained by partial self-suspension by means of a 
pulley and head-swing. Bradford uses, in cases which are markedly resistant and 
in growing patients where rigidity is not complete, permanent plaster-of-Paris jack- 
ets, exerting a correcting pressure upon the abnormally prominent ribs, while the 
jacket is still soft, from behind forward and from before backward, by means of a 
screw force extending from a circular steel ring which is placed around the patient's 
trunk temporarily while the jacket is being applied. 

Steele recommends a raw-hide jacket. Phelps uses an aluminium corset (Trans. 
Amer. Orthop. Assoc, 1893), or one of wood-shavings (Waltuck Method, New 
England Medical Monthly, February, 1892), and Vance one of paper. Roberts 
("Transactions Ninth International Congress," vol. iii.) has devised a wire corset, 



Appendix 785 

designed to exert a continuous elastic pressure. Shaffer uses a light steel appa- 
ratus, adapted to exert pressure in the desired direction, at the same time allowing 
some antero-posterior movements of the trunk. Exercises are systematically used 
in addition. 



DISEASES OF THE BONES. 

Ununited Fractures (p. 597). — Ridlon, in cases of delayed union in fractures 
of the leg (New York Medical Record, January 31, 1891), following Thomas, advo- 
cates the use of the latter's caliper splint, but so modified as to permit of no motion 
at the ankle, and with a laced leather leg-sleeve added. 

The advantages claimed over plaster-of-Paris are better immobilization, and no 
constriction at the seat of fracture. The apparatus allows the patient to go about 
during treatment and permits the production of cedema by damming. 



DISEASES OF THE JOINTS. 

Origin (p. 631). — Northrup has given some instructive records of autopsies 
bearing on this point (New York Medical Journal, February 21, 1891). He 
found that the primary seat of tubercular infection was in the bronchial lymph- 
nodes in a great majority of cases. In 125 cases examined, 34 had too extensive 
lesions to determine which was primary ; 20 had the oldest lesion in the respiratory 
tract; 42 had cheesy masses in bronchial lymph nodes only, more recent tubercules 
were found in lungs and elsewhere. In 9 all the tubercular process was confined 
to these nodes and the lungs. In 13 it was limited to the nodes alone. 

Abscess in Joint Disease (p. 625). — The treatment of tubercular abscesses 
has always been a matter of debate. Townsend (Trans. Amer. Orthop. Assoc, 
1891) has found that nearly fifty per cent, of a large number of cases which he col- 
lected and analyzed were by repeated aspirations relieved and the abscess eventu- 
ally disappeared. Some surgeons incise and drain them as soon as fluctuation is 
found, whether they have become infected or not. 

In a paper on " Operative Interference in Abscess of Chronic Tubercular Disease 
of the Joints," read before the New York Academy of Medicine, in October, 1S95, 
Shaffer said that he waited until there were severe general or local symptoms due to 
the abscess itself before he incised it. So long as we knew of its existence by 
sight and touch only, we were justified in ignoring it. He found that many 
of them disappeared, and few, if any, gave rise to trouble, and that those which 
opened spontaneously uniformly did well. In the adult and adolescent, an invariably 
favorable prognosis could be given if the non-operative method be adopted together 
with efficient mechanical treatment, whereas the prognosis was not so certainly good 
if the abscess were operated upon. The efficiency of the mechanical treatment 
was, of course, very important. There are cases in which mixed infection occurs 
and in which there may be symptoms indicating a minor degree of septicaemia. 
Even here Shaffer advised waiting awhile before incising. If the joint is properly 
protected, the urgent symptoms will probably subside. If theypersist, a free in- 
cision must be made. Ordinarily the abscess should be allowed to open spontane- 



786 Diseases of Children 

ously, then simple external dressings are applied and the parts kept clean with per- 
oxide of hydrogen or bichloride of mercury. The ultimate recovery of the joint 
is better under the non-operative treatment than after incision of the abscess. 

Dane has endeavored to find a method of discovering whether these cold ab- 
scesses have become infected or not, and has published his work in a recent number 
of the Affierican Journal of the Medical Sciences. His conclusions are : 

1. Most cases of tuberculosis of the bones and joints do not decrease the 
number of the red corpuscles in the blood. 

2. They do, however, affect the percentage of haemoglobin, giving rise, in fact, 
to a mild degree of chlorosis. 

3. The leucocyte count seems to have no special relation to the tempera- 
ture. 

4. High counts, especially in hip disease, point to the probability that there is 
or shortly will be abscess formation, but low counts do not preclude the presence 
of pus, especially in long-standing cases. 

5. Where an abscess is found in the face of a low leucocyte count, the pus 
from it is sterile, that is, does not contain pyogenic organisms: it does often contain 
tubercle bacilli. The case is generally one of long standing. 

6. In the presence of an abscess a low leucocyte count indicates the absence 
and a high count the presence, of a secondary infection with pyogenic organisms. 

7. Cases where at the primary operation the pus has proved sterile, generally 
show an increase in the leucocyte count, and especially in the differential count, 
where the wound becomes infected with the pyogenic organisms. 

8. High total leucocyte counts do not always affect the differential count. 
Dane in these investigations used the Thoma-Zeiss apparatus. The red pipette 

was diluted 1-200 with " Toison's solution," and the white in a separate pipette 
1-100 with 3£ acetic-acid solution and a little methylene violet. The dry slides were 
hardened in benzine, and stained with Ehrlich's triple stain. 

Case I. — Boy six years old. Hip disease, one and a half years' duration. De- 
veloped an abscess about four months previously. Entered with large fluctuat- 
ing tumor both in front and behind joint. Operation showed ^ v greenish puri- 
form material. Head of bone nearly separated, and rim of acetabulum much 
roughened. 

Blood count : 

Erythrocytes 6,096,000 

Haemoglobin 75^ 

Leucocytes 6,756 

Lymphocytes 28$ 

Large mononuclear and transitional forms 12$ 

Polynuclear neutrophiles 58$ 

Eosinophiles 2% 

Pus proved sterile from pyogenic organisms. 

Case II. — Girl three years old. Hip disease, seven months' duration. Abscess 
for two months. Large fluctuating swelling on anterior aspect of thigh over great 
trochanter. Operation gave ^ vi pus, and showed a sinus leading into the joint, 
which was not much disintegrated. 



Appendix 787 

Blood count : 

Erythrocytes 3, 744. °°° 

Haemoglobin . 65$ 

Leucocytes 4 I ,36o, 

Lymphocytes 14$ 

Large mononuclear and transitional forms S% 

Polynuclear neutrophiles 8i# 

Eosinophiles 0% 

Pus showed the presence of Staphylococcus pyogenes aureus and Staphylococcus 
pyogenes albus. 

Mechanical treatment. Shoulder (p. 616). — To apply extension at the 
shoulder Shaffer uses an axillary crutch, to which is attached an extension-bar run- 
ning down the inner aspect of the arm, and terminating in a band which half 
encircles the arm. Adhesive straps are applied and fastened to this band, and the 
extension-bar lengthened as required. 

Townsend (Trans. Amer. Orthopedic Assoc, vol. vii.) claims that the usual 
termination of this disease under mechanical treatment is ankylosis more or less com- 
plete, as a rule limiting the ability to raise the arm from the side to about one-third 
or one-fourth the normal amount. This loss of function is a serious matter in 
many cases, and only such work can be done in severe cases as requires but little 
force, and such as can be supplied by the forearm alone. When the patients can 
get the hand to the head to feed and dress themselves the condition is not so seri- 
ous. Townsend claims that after partial or complete excisions much more freedom 
of motion can be obtained in most cases. Rejecting the statistics of pre-antiseptic 
days the operation does not appear to be dangerous. The joint is easy of approach, 
and in a large majority of instances the disease is located in the head of the 
humerus, and can thus be entirely removed. By partial operations and the sub- 
periosteal method the growth of the limb should not be much affected. In regard 
to mechanical treatment Townsend says that in no case that he had treated was 
this method given a fair trial, but that from careful reading and the examination 
of some patients supposed to have been subjected to careful mechanical treatment 
he had been led to the belief stated above. 

Mondan and Audry (Revue de Chirurgie, 1892) found as the results of thirty- 
two excisions, all done on patients near adult life, that the starting point of the 
disease was in twenty-nine cases in the bone, in one doubtful, and in three it was 
clearly synovial. In twenty-three of these cases the disease originated in the 
humerus, in four in both the scapula and the humerus, and in one in the scapula. 

Elbow (p. 616). — To immobilize the elbow Myers uses a splint formed by 
wires that follow the upper and lower borders of the hand and forearm, the an- 
terior and posterior borders of the arm, and then descend on the side of the body 
to the waist-line ; a laced sleeve holds the hand and forearm, and another the 
arm. Thoracic and abdominal straps hold the splint firmly against the body. 
This controls the short limbs of children well. 

Wrist-joint. Excision (p. 617.)— Mynter (Trans. Amer. Orthpedic Assoc, 
vol. vii.) considers the results of iodoform injections excellent, and therefore thinks 
early operation distinctly contraindicated. Excision should only be resorted to in 



788 



Diseases of Children 



old and neglected cases, and in these it is impossible to remove by the usual longi- 
tudinal incisions of Oilier and Lister the fatty, degenerated, softened, and carious 
bones except in piecemeal, leaving a large amount of the tuberculous bony tissue 
and a still larger amount of the tuberculous synovial tissue in the wound. Pro- 
tracted suppuration and tuberculous relapses necessitating repeated operations, and 
possibly amputation, may follow. In-order to gain free access to the diseased focus, 
Mynter, following the suggestion of Studsgaard, advocates a complete splitting of 
the hand from before backward, but he makes his longitudinal incision between 
the second and third metacarpal bones, then entering between trapezoid and os 
magnum, and between scaphoid and semilunar bones, as the hand is more evenly 
divided by this incision than by the one recommended by Studsgaard, which passes 
between the third and fourth metacarpal bones, and then opens up the joints be- 
tween os magnum and unciform bone, and between semilunar and cuneiform 
bones. Mynter operated in March, 1894, by this method. He made the dorsal 
incision reach up to the radius, but found it unnecessary on the palmar side to ex- 
tend the incision farther than the base of the thenar of the thumb. The annular 
volar ligament was, therefore, not severed. By careful 
dissection from the dorsal side, and forcible separation, 
he found it easy to avoid wounding the dorsal tendons 
and the large palmar tendinous bursa. The whole car- 
pus could now be widely opened, and it was extremely 
easy with scissors to extirpate the two halves of the 
carpus, and with a fine saw to remove the surfaces of 
the radius, ulna, and the metacarpal bones. The cavity 
was packed with iodoform gauze. The wound healed 
promptly and the result, eight weeks after the operation, 
was extremely gratifying. The patient can actively ex- 
tend and flex the wrist and move the fingers, but there is 
still some looseness of the wrist-joint, though it is 
steadily getting firmer. Mynter considers this opera- 
tion far superior to Ollier's and Lister's longitudinal, or 
the old transverse incisions, as by these last methods 
we necessarily get adhesion of the tendons to the cica- 
trix. 

Hip-joint. — In the United States all surgeons agree 
that during the acute symptoms of hip-joint disease the 
limb must be immobilized as perfectly as possible. 
Traction is applied during this time to overcome the 
reflex muscular spasm almost as invariably. After the 
pain and deformity are overcome, the practice varies somewhat. Some few rely 
on immobilization alone, using a plaster-of- Paris, spica, or a Thomas hip-splint, or 
similar device. The large majority, however, combine traction with immobiliza- 
tion, more or less complete, until all reflex muscular spasm has disappeared. After 
this the joint is still protected from pressure for months to avoid a relapse. In 
the United States, therefore, the long traction hip-splint (Davis-Taylor) (Fig. 194) 
is used almost exclusively until the convalescent stage. Then Sayre sometimes 




Fig. 194.— The Davis-Taylor 
Long Traction Hip-splint. 



Appendix 



789 



uses his short traction splint, or, like Shaffer, Taylor, and Bradford, a perineal 
crutch permitting motion at the knee and affording a modified protection from the 
traumatism of percussion. 

Where the child is large or very heavy the use of axillary crutches, in addition to 
the hip-splint, will be advantageous in some cases. As much traction is applied by 
the hip-splint as can be borne with comfort by the 
patient. Where slight traction causes pain, this is 
due to the tension of an abscess under the fascia lata. 

Knee-joint (p. 627). — Traction is successfully 
used also at the knee to reduce the deformity and 
relieve the pain. It must be applied in the direc- 
tion of the deformity, and continued as long as 
there is any reflex muscular spasm. Sayre's ex- 
tension knee-brace is, perhaps, the one best known. 
Where there is deformity New York surgeons em- 
ploy traction for a longer time than is recommended 
in England (p. 631), before resorting to forcible 
manipulations, as many cases which will not yield 
in a few weeks will do so in a few months, and 
all traumatism will thus be avoided. Many sur- 
geons who apply traction at the hip-joint, how- 
ever, are content to protect the knee-joint from 
motion and percussion. 

Shaffer recommends a splint for cases of sub- 
luxation (p. 631) unless there is ankylosis, which 
exerts forward pressure on the head of the tibia, 
and longitudinal traction in the line of the de- 
formity (Archives of Clinical Surgery, June, 1877). 

Goldthwaite (Bost. M. & S. Jour., Sept. 7, 
1893) describes a very admirable modification of 
Bradford's apparatus for correcting posterior sub- 
luxation of the head of the tibia in cases where 
there is no bony ankylosis. Under anaesthesia 
the adhesions are broken up carefully by one or 
more applications of the lever, and a protective 
splint worn afterwards until the disease is cured 
(see Fig. 195). 

Amputation (p. 633) for tubercular disease of the knee-joint, without other 
Usions, is very rarely done here. Gibney has had but one case requiring it in the 
last i\ve years at the Hospital for the Relief of the Ruptured and Crippled ; at the 
New York Orthopedic Hospital this operation has not been advised or done in 
that time. 

HIP DISEASE. 

Muscular Spasm (p. 645).— Involuntary reflex muscular spasm is generally con- 
sidered in America the most constant symptom o\ hip disease. It appears first and 
disappears last, and is the safest guide as to the presence or absence of the disease. 




Fig. 195.— Bradford-Gold thwaite 
Brace for Correcting Deformity 
at the Knee. 

To apply the brace : The head of 
the tibia is forced forward as far 
as possible by the screw " b " work- 
ing- in the arch "a," which raises 
the cross bar " c " to which the pos- 
terior band " d " is attached by the 
steel loops " e." The counter-press- 
ure is exerted by the straps " f " 
and " g." The leg is then carefully 
straightened by the lever arm " h.' 1 



790 Diseases of Children 

The writer during his observations of hip-joint disease under the tuberculin 
treatment at St. Luke's Hospital, made daily careful examinations, and came to 
the conclusion that the reflex muscular spasm was the first symptom affected by the 
injections. In the cases with more marked reaction the symptoms, although last- 
ing but a few days, exactly resembled the usual exacerbations of the disease, with 
increase of reflex spasm, less motion, or even appearance of deformity, increase of 
pain and sensitiveness, and recurrence of night cries. In less marked reactions 
several times the reflex muscular spasm became more alert, though there was no 
rise of temperature, nor appreciable increase of joint-sensitiveness or decrease in 
motion. One case he had examined repeatedly six weeks after all pain, deformity, 
and limp had disappeared, and the reflex spasm was always detected. 

Deformity (p. 657). — Exacerbations sometimes follow rapid reduction of the 
deformity under anaesthesia. When traction is used for this purpose it must be 
applied in the line of deformity, whatever the position of the limb may be. 

Phelps ("Transactions New York State Medical Society," February, 1889) 
strongly recommends that traction be made in the line of the axis of the neck of the 
femur, not in the axis of the shaft. 

Phelps (p. 645) explains the deformities of the different stages of hip-joint 
disease as follows : The first stage is produced by voluntary effort on the part of 
the patient, aided by spasm of the muscles, in order to relieve the tension of the 
Y-ligament and capsule of the joint ; hence abduction, outward rotation, and flexion. 
Muscular spasm and a voluntary effort exaggerate the deformity of the first, pro- 
ducing that of the second stage. When flexion takes place beyond thirty degrees, 
and often with less flexion, the limb rapidly assumes the position of the third stage 
(with an occasional exception), adduction, inward rotation, and flexion, for the 
following reasons : when the limb is thus flexed the glutei muscles and the tensor 
vaginae femoris become inward rotators. The glutei cease to be abductors, and the 
external rotators are no longer rotators but abductors, with the exception of the 
quadratus femoris and obturator externus. The adductors, now being no longer 
antagonized by the great glutei muscles, cause the adduction. 

The erratic deformities he accounted for by destruction of bone changing or 
destroying leverage, burrowing of pus, dislocation, perforation of acetabulum, and 
locking of the head of the femur in the pelvis ; possibly by the location of the 
lesion, adhesions, and irritation of special nerve-plates supplying the joint. The 
fluid tension hypothesis he thought erroneous, because many cases were unattended 
by effusion, and many cases of all the deformities seen in hip-joint disease were 
extra-capsular. 

Results (p. 653). — Sayre {New York Medical Journal, April 30, 1892) shows 
that in 407 cases treated by him without excision, the ultimate result was : 

Cure, motion perfect 71 

" " good 142 

" " limited 83 

' ' ankylosis 5 

Unknown 78 

Under treatment, 14 ; abandoned, 3 ; discharged, 2. Total deaths, 9. 



Appendix 



7 9 r 



As the Thomas hip-splint (p. 610) does not afford traction it is not commonly 
used in the United States. 

Excision of the Hip (p. 657). — In general there is a strong conservative feel- 
ing at present among American orthopedic surgeons on the question of hip-joint 
excision. It is considered a last resort, to be applied only in exceptional cases 
where conservative treatment cannot be carried out, or as a means of saving life. 
Bradford and Lovett express the general feeling when they say, " It must be borne 
in mind that the ultimate results after early excision are much more favorable than 
after late excision. Where a late excision is done the surgeon will always regret 
that the operation had not been done before. The results of careful conservative 
treatment, if carried out for a long time, are superior to those after excisions in a 
majority of cases, and where conservative treatment is practicable it should be pre- 
ferred. In large hospitals or among the poor and unintelligent class conservative 
treatment is sometimes impracticable, and in such cases excision is resorted to earlier 
than would otherwise be justifiable, and the results gained are more satisfactory 
than when the operation is deferred." 



SPINAL DISEASE. 

Symptoms (p. 669). — Myers has seen in several cases of high cervical disease 
severe attacks of dyspnoea and heart-failure, probably due to pressure on the cord, 
two of them ending fatally. 

Treatment (p. 671). — Recumbency is strongly advocated 
by Steele {Medical Fortnightly, February 1, 1891), who 
straps his patient to a canvas-covered iron frame and ap- 
plies head traction when the disease is in the cervical and 
upper dorsal regions (see also Bradford and Lovett, "Or- 
thopaedic Surgery," p. 54, and Schapps, Medical Record, Sep- 
tember 9, 1893). 

Taylor's spinal-assistant brace (Fig. 196) is also largely 
used in America (p. 671) for disease in all regions. When 
the disease is above the seventh dorsal vertebra a chin-cup 
with occipital uprights is attached to the brace by means of 
a ball-and-socket joint, placed as near the occipito-atloid joint 
as possible, and the head can then be held in any position 
desired. 

Taylor (p. 672) {Medical Nezvs, No. 1,158, p. 317) has 
devised a safe, efficient, and easy method of applying a plaster- 
of- Paris jacket. The patient sits upon a bicycle saddle 
with feet resting on and fastened to rigid stirrups. The 
hands grasp handles above and a little behind the head, so 
hyperextending the spine. Head suspension can also be 
added if necessary. In this way, without fatigue, without 
motion, and with rapidity a jacket can be applied to either 
a child or a heavy adult, and the support can be carried higher 
readily done by the other methods. 

Lloyd (p. 676) {Annals of Surgery, October, 1892) has tabulated all published 




Fig. 196.— Taylor's Spin- 
al Brace with Chin cup. 



up in 



front than is 



79 2 Diseases of Children 

cases of laminectomy in Pott's disease up to September, 1892, as well as several not 
previously reported. He concludes that the operation is definitely indicated in a 
certain limited class of cases. 

Gibney (p. 676) {Journal of Mental and Nervous Diseases, April, 1878), Taylor 
and Lovett (New York Medical Record, June 19, 1886). Myers ("Transactions 
American Orthopedic Association,". 1890), and Huddleston {American Journal of 
Medical Sciences, August, 1894) have presented statistics on a large number of these 
cases, showing the frequency of recovery from the paralysis without operation. 

CLUB-FOOT. 

Shaffer (p. 680) (New York Medical Record, May 23, 1885) described a condi- 
tion of modified flexion at the ankle and a contracted state of the plantar tissues 
which he called non-deforming club-foot. The symptoms were awkward gait asso- 
ciated with painful callosities at various parts of the foot ; or in more severe cases 
actual disability, pain in various parts of the foot, ankle, and leg, and even reflected 
to the lumbar region ; also tender and inflamed articular surfaces, especially at the 
junction of the first metatarsal bone with its phalanx. 

Wilson (p. 683) (" Transactions of the American Orthopedic Association, 1892 ") 
advocates "the complete reduction of the deformity by the end of the first month 
of life, by simpler means if possible, by tenotomy otherwise. The muscular power 
of the foot should be developed as much as possible afterward." Most surgeons 
would be willing to wait longer before resorting to operation. 

It is but just to say that the surgeon meets a large class of cases which have 
been neglected for two or three years or more. These cannot be corrected by the 
simpler forms of splints, yet can be saved from operative treatment by the use of 
suitable stretching splints applied by a surgeon who knows how to use them. 

The importance of maintaining the corrected position cannot be overestimated. 
Many of these deformities will surely and slowly recur, whether they have been 
cured by operation or without it, unless exercises, massage, and attention to the 
manner of walking are kept up for a year or so. 

Phelps (p. 687) recommends the following order of operation, that one may fol- 
low the other at once if required : I, strong manipulation ; 2, subcutaneous tenot- 
omy ; 3, open incision ; 4, linear osteotomy of the neck of the astragalus ; 5, V- 
shaped piece removed from body of os calcis ; 6, removal of cuboid and scaphoid ; 
7, Pirogoff's amputation. Exceptionally the order may be changed, so that after 
4. excision of the astragalus may be performed. 

Bradford (" Transactions of the American Orthopedic Association, 1892 ") found 
that " when the foot could not be brought straight after section of all the soft parts 
on the inner side of the foot, the resistance was generally located in the neck of the 
os calcis, and he advocated in these cases the excision of a wedge from this bone 
just posterior to the line of cartilage " He said : In a normal foot a line drawn 
through the middle of the sole is a straight one, but in case of club-foot after the 
removal of the astragalus the median line in front of the medio-tarsal articulation 
formed an angle with the median line posterior to the articulation. This was due 
to the obliquity of the anterior facet of the os calcis. See also Phelps's article on 
this subject {University Medical Magazine, March, 1892). 



Appendix 



793 



Parrish (p. 687) {Medical Journal, October 8, 1892) describes a method he has 
devised of suturing live tendons to those paralyzed, and so regaining lost function. 
He has sutured the healthy extensor pollicis tendon to the paralyzed tibialis-anticus 
tendon to remedy a case of valgus. 

Whitman (p. 690) ( New York Medical Journal, November 9 and 16, 1895) has 
devised an arched steel sole for the treatment of flat-foot which acts as a lever to throw 
the inner edge of the foot up in walking and yet is so short that it does not restrict nor- 
mal muscular action. If the foot can be replaced in proper position, if its movements 
are free and not limited by muscular spasm or inflammatory adhesions the sole can 
be applied at once, and with a proper shoe, an avoidance of faulty positions, and exer- 
cises for strengthening the weakened muscles the patient will be at once relieved. 




Fig. 197.— Whitman's Flat-foot Support. 



A. Astragalo-scaphoid joint. 
C. Ball of great toe. 



B. Calcaneo-cuboid joint. 
D. Middle of heel. 



If, however, the reduction by manipulation is impossible, the foot should be forcibly 
moved, under anaesthesia, in all directions to break up adhesions, and then forced 
into a position of extreme adduction or equino-varus and retained there in a well- 
padded plaster bandage. Although great force is sometimes used, the after symp- 
toms are usually slight, and the patient, if he desires, may walk about on the plaster 
bandage the following day. In from one to three weeks the bandages are removed 
and active treatment begun. The foot is now, though in good position, stiff, and 
all its movements are restricted and painful. It is, therefore, immersed in hot 
water, massaged, and slowly forced into a position of adduction. Voluntary exor- 
cises are then executed for twenty minutes. These are repeated several times a 
day and the surgeon once daily forces the foot into the hyper-corrected position. 
The sole is made of thin steel molded while hot on an iron cast of the foot in its 
corrected position, and is then tempered so that it is unyielding under the weight 
of the body. Fig. 197 shows the form and application of these supports. Whit- 
man calls attention particularly to the following points : 



794 



Diseases of Children 




i. That there should be an accurate adjustment of the support to the cast of the 
corrected foot : (it is never applied to a stiff and deformed foot). 

2. Lateral support is afforded as well as support from beneath, and thus is pre- 
vented the dislocation of the astragalus, the abduction and valgus, the important 
elements of so-called flat-foot. 

3. Leverage. The weak foot, properly balanced in a Waukenphast shoe, and used 
properly, will press the outer arm against the sole, and thus tighten the inner 
flange of the brace against the astragalo-scaphoid junction, where the prelimi- 
nary bulging, the first sign of flat-foot, appears. 

4. Non-interference with the functions of the foot. The component parts being 
held in proper relation to one another, the foot may again become strong by 
proper exercise, the proper walk, and proper attitude, and the brace may then be 
discarded. 

Shaffer has found that in very many cases a shortening of the tendo Achillis 
precedes the appearance of flat-foot. Flexion being prevented at the ankle-joint 
occurs at the medio-tarsal joint. He therefore advocates restoring to this tendon 
its normal length, as a necessary part of the treatment. 

A very early sign of commencing flat-foot is a rotation of 
the whole foot on an antero-posterior axis, therefore lateral 
support to the astragalus is important. As, after the bones 
have been restored to the normal positions, a cure of the de- 
formity must be maintained by increased muscular power, and 
as direct pressure weakens the muscle pressed upon, all steel 
soles and springs are theoretically objectionable. 

The treatment adopted at the Orthopedic Hospital to meet 
these indications is correction of the shortening of the tendo 
Achillis by forcible intermittent stretching, or tenotomy if 
necessary ; correction of the rotation of the whole foot on the 
antero-posterior axis by manual or mechanical force ; correc- 
tion of the abduction of the toes in the same way, and main- 
tenance of the corrected position by the use of steel ankle 
supports, riveted to the shoes, allowing free flexion and ex- 
tension at the ankle-joint and so encouraging muscular de- 
velopment, yet affording firm lateral support to the tarsus and 
also holding the inner side of the foot a little higher than the 
outer side, which, therefore, is made to carry most of the weight 
in walking. (See Fig. 198.) 

Torticollis (p. 692). — The Taylor spinal-assistant brace, 
with its chin-piece and occipital uprights, is well suited to 
these cases. It can be readily adjusted to any position of 
the head, and as easily re-adjusted to an improved position. 

Keen (Annals Surgery, October, 1891), Gardner (Australian Medical Journal, 
February, 1893), Powers (New York Medical Journal, 1892, p. 253), and others 
have resected the posterior branches of the upper cervical nerves with success after 
resection of the spinal accessory had failed. 

Genu Recurvatum (p. 702). — Myers, in examining a considerable number of 




Fig. 198 — Shaffer's 
Flat-foot Support. 
1. Astragalo-scaphoid 
pad. 2. Inner side of 
sole piece raised high- 
er than outer side, 3. 



Appendix 795 

cases of genu recurvatum, found that the patellae generally develop later on, though 
they may not be found at birth. 

Arrest of Development (697). — Hasse and Dehner (Arch. f. Anat. u. Physiol. 
Abtheil., 1893) have found that in the majority of cases the lower limbs are of un- 
equal length, that asymmetry is the rule and not the exception. 

Club-hand (p. 697). — R. H. Sayre (New York Medical Journal, November 4, 
1893) operated upon an aggravated case in which the radius and thumb were 
absent, as well as the first metacarpal bone and a certain number of the carpal 
bones. The marked curve in the ulna was first corrected by osteotomy. After 
union in a straight line was secured, and after several weeks of stretching the con- 
tracted tissues had failed, the styloid process of the ulna was cut off, the os magnum 
and unciform removed, and the end of the ulna put into the gap in the carpus thus 
formed. The hand is now approximately in line with the forearm. There is free 
motion at the wrist, and the ability to grasp objects is greater than it was before 
the operation, though extension of the hand is poor. 

Congenital Dislocation of the Hip (p. 701). — Gibney (Annals Surgery, 
December, 1894) says that the results he has obtained in his cases of congenital 
dislocation of the hip from Hoffa's operation have been far from satisfactory. He 
reports on six cases. He attributed his ill success to some fault of technique, 
since suppuration followed the operation in the majority of cases. The age also 
of his patients was too far advanced in most of the cases. 

Bradford (Annals Surgery, xx., No. 2, p. 129) found that contraction of the 
anterior fibres of the capsule may sometimes prevent reduction. 

Paci (Arch, di Ortop., Ann. ix., No. 6, and Ann. x., No. 1) reports on fifteen 
cases treated by his method, and the results are almost perfect a year or more after 
operation. His method is to forcibly manipulate the limb, as if to reduce a 
traumatic dislocation — that is, the limb is first forcibly flexed as far as possible, 
then abducted, then rotated outward, then extended. Afterwards the thigh is held 
completely extended and immobilized, and traction applied. If the shortening is 
not completely overcome at the first operation, a subsequent one will probably 
accomplish the reduction. In about two months the plaster-of-Paris splint is 
removed and an extension apparatus applied. Four months after the operation 
the patient is allowed to get up and walk with crutches. At night the extension 
is reapplied. The limb is massaged twice daily, and once a day receives electrical 
treatment. 

Schede's recently recorded cures of this condition by conservative treatment 
seem to indicate that a persistent attempt should be made to cure without resort- 
ing to the open operations of Hoffa and Lorenz, if this is practicable. The results 
from operation should improve with improved technique and more careful after- 
treatment. Myers (Annals Surgery, December, 1S94) found the mortality in one 
hundred and seventy-three recorded cases three and three-tenths per cent. 



796 Diseases of Children 



MILK. 

A superstitious belief in the superior virtues of the milk of "one cow" is still 
common among the public, and it is often looked upon as a most important matter 
to secure this. As a matter of fact, a good average milk is more likely to be 
obtained from mixing the milk of a number of cows than in taking it from one, for 
it is well known that the first portion of milk obtained from the udder is poor in 
fat. while the last portions are rich, the amount varying from two to eight per cent. 
If the first part of the milk taken is reserved for the infant, it is tolerably certain 
to get a poor milk. Whenever a cow is specially reserved to supply milk for an 
infant, care should be taken to see that it is not an old one, and the last portions 
of milk should be taken for the child. 

What is of far more importance than the question of " one cow" is the question 
as to how the cows are fed, and the care taken to prevent the contamination of the 
milk with organic matters. In the vicinity of our large towns it is no uncommon 
thing to see cows out at pasture in fields watered by brooks contaminated with 
sewage, of which they freely drink ; moreover, they are extremely likely to lie 
down in the sewage water, and their udders, and consequently the milker's hands, 
become befouled with sewage. In the winter time the cows are frequently fed 
largely on turnips and brewer's grains, instead of hay, maize, or other dry fodder ; 
possibly also their sheds are infrequently cleaned out and only sparingly supplied 
with straw, so that the animals lie in fasces and their udders may be seen caked 
with dried excrement. It is no uncommon thing to find a greenish-looking sedi- 
ment in milk from second-rate dairies, due to contamination of faecal matters. The 
storage of milk is an exceedingly important matter, for milk readily absorbs gases, 
and is readily contaminated when kept in cellars or kitchens pervaded with sewer- 
gas or the emanations of decomposing animal substances. The temperature at 
which it is kept is also important, as it far more quickly turns sour and decomposes 
when kept in a warm place than in a cool place. This is recognized by many milk 
purveyors, who at once take measures to cool the milk directly it is received from 
the cow. According to Soxhlet fresh milk turns sour and curdles at the following 
temperatures and times : 

At 32 C. (90 F.) in 19 hours. 
At 25 C. (77 F.) in 29 hours. 
At I7i° C. (63. 5 F.) in 63 hours. 
At io° C. (40 ° F.) in 208 hours. 
At o° C. (32° F.) in 3 weeks. 

" Modified Milk." — Feeding of infants requiring a substitute for breast milk. 
American practice in the vicinity of milk laboratories has satisfied itself that 
"modified milk " is the most successful substitute feeding. In round statement, 
the composition of cow's milk may be set down as : 

Fats, 4 %. 
Sugar, 4 %. 
Albuminoids, 4 %. 



Appendix 797 

High average breast milk may be set down as : 
Fats, 4 %. 
Sugar, 7 %. 
Albuminoids, 2 %. 

A low average may be set down as 

Fats, 3 % 
Sugar, 6 % 
Albuminoids, I % 

With these three sets of figures in mind in a majority of cases the practitioner 
may " modify" the proportions of fats, sugar, and albuminoids to the needs of the 
child, changing the proportions according to the indications ascertained from ob- 
serving the nature of the passages and the general condition of the child. His 
orders for varied proportions he writes in a prescription. 

For a newborn, upon the third day, the beginning proportions may be tempo- 
rarily lower in percentages. 

Fats, 2 % 

Sugar, 5 or 6 % 

Albuminoids, 0.75 % 

Futhermore with these figures in mind it is not impracticable with the aid of 
the Babcock cream-tester and the sugar solution to prepare approximately a modi- 
fied milk in a home-made laboratory. Such a laboratory is in use in two of the 
institutions for the care of young infants in New York. 

It is the earnest hope of the profession of America that the feeding of infants may 
be kept within the domain of physicians and without necessary reliance upon the 
made-up foods of commercial firms. Cow's milk when modified to the proportions 
of fats, sugar, and albuminoids found in breast milk offers at present the most 
available and practicable infant substitute feeding. For exactness in modification 
a well-equipped laboratory, such as exist in Boston and New York, is requisite. 

Professor Rotch, of Harvard University, has taught the profession to think in 
percentages, and has brought to practical completeness, by the aid of the Walker- 
Gordon Laboratory, prescription writing and exact modifying of milk. 

The Pasteurization of Milk. — Pasteurization consists of two essential opera- 
tions of equal importance. (1) Sterilization at 75 C. = 167 F., followed by (2) 
rapid cooling to about io° C. = 50 F. The adoption of pasteurization has been 
due to our knowledge that such a procedure will destroy the pathogenic germs 
most feared in milk ; those of typhoid fever, diphtheria, cholera, and tuberculosis, 
as well as the Staphylococcus pyogenes aureus, the Streptococcus pyogenes, the 
Coli communis and the Pneumococcus. It also destroys most of the non-pathogenic 
bacteria. On the other hand pasteurization does not produce those chemical 
changes in milk which are produced by sterilization at ioo° C. = 212 F., and 
which render the milk less digestible and less nourishing. 

A milk pasteurizer known as Dr. Freeman's apparatus has recently been placed 
before the profession. This apparatus is simple and inexpensive and produces 
in the milk a fairly definite temperature of 75° C. = 167 F., without the use 



79 8 



Diseases of Children 



of a thermometer, and is provided with a contrivance for rapid cooling. The 
apparatus consists of two parts : (199) a pail, and (200) a receptacle for the bottles 
of milk. The pail is an ordinary pail with a cover. Encircling the pail is a 
groove to indicate the level to which it is to be filled with water. The receptacle 
for the bottles of milk consists of a group of cylinders, each cylinder large 
enough to hold one bottle. 

In using the apparatus, the pail is filled to the level of the groove with water 
and placed on the stove, the receptacle for the bottles of milk having been taken 
out. The bottles are filled with milk, stoppered, and placed in the cylinders of 
the receptacle. The space surrounding the body of the bottles in the cylinders 
is filled with cold water. When the water in the pail boils vigorously, the pail 
is taken from the stove and the receptacle containing the bottles of milk is placed 
in the pail (Fig. 199). The pail is then covered and allowed to stand on a table 
or the floor for half an hour. During this time an equalization of temperature 
takes place between the hot water and cold milk. During the first ten minutes 
the temperature of the milk rises to about 75 C. = 167 F., and remains there 
during the following twenty minutes. At the end of half an hour the cover 





Fig. 199 and Fig. 200. — Dr. Freeman's Pasteurizing Apparatus. 

of the pail is removed, the receptacle is elevated (Fig. 200) and the pail is placed in 
a sink under a faucet, from which cold water is allowed to run into the pail, thus 
replacing the hot water and cooling the milk. In twenty minutes the milk reaches 
about the temperature of the surrounding water and should be put in a refrigerator 
until used. 

Pasteurized milk should be used only during the twenty-fours hours following 
pasteurization. 

BARLEY WATER. 



Place a tablespoonful of best pearl barley in an enamelled saucepan, add a pint 
of water, and boil for a few minutes, stirring all the time so as thoroughly to cleanse 
the grain. Pour the water off the barley, replace by a pint and a half of clean 
water, and simmer gently for an hour, and strain. Another and better method is 



Appendix 799 

to use barley meal prepared from the whole grain, inasmuch as the greater part of 
the gluten is found in the cells lining the husk (Jacobi). The grain should be well 
washed and ground in a coffee-mill kept for the purpose. The barley water used 
during the early months of infancy should be a thin mucilaginous fluid ; in the later 
months it should be thicker, or barley jelly may be used to thicken the milk 



OATMEAL WATER. 

A table-spoonful of coarsely-ground oatmeal should be placed in a pint of water ; 
simmer gently for an hour, replace the water evaporated. 

ARROWROOT WATER. 

Take two tea-spoonfuls of best arrowroot and a pint of water ; simmer for five 
minutes, stirring constantly. 

WHEY. 

Warm a pint of milk to blood-heat ; add a tea-spoonful of ' artificial rennet ;' in 
a few minutes the curd will have separated from the whey ; break up the curd with 
a fork and allow it to stand till the curd has subsided ; decant and boil the whey. 
Whey thus prepared may be given to a newly-born infant, cream or milk being 
added according to its powers of digestion. Whey with some added brandy is use- 
ful as a substitute for 'white wine whey,' and generally agrees better. 

VEAL TEA. 

Take one pound of veal free from fat and bone, cut into small pieces the size of 
dice, place in a covered jar with a pint and a half of water or barley water, cold ; 
place in an oven not too hot, and bake for three or four hours — or it may be left in 
the oven all night : strain and remove fat. 



SCRAPED MEAT. 

Take a thick rumpsteak of the best quality ; scrape it with a knife until reduced 
to shreds. A sandwich can be made by placing a small portion between very thin 
slices of bread and butter. Some children will take the meat pulp out of a tea- 
spoon or mixed with gravy or beef-tea. Scraped meat can also be prepared from 
rumpsteak which has been frizzled for a few moments on a quick fire, the burnt 
outside being cut off before being scraped. 

RAW MEAT JUICE. 

Finely mince a pound of the best rumpsteak freed from fat. Place in an earthen 
vessel with sufficient cold water to well cover it, add some lump sugar, and let it 
stand for four hours. Strain through muslin. It can be given with port wine if 
thought desirable. 



800 Diseases of Children 



LINSEED MEAL POULTICE. 

Warm a basin, pour in boiling water ; sprinkle in the meal, stirring vigorously, 
till it becomes of the consistency of thick porridge ; spread on tow or old linen, 
turning in the edges all round ; before applying put it against one's cheek to feel 
that it is not too hot. Retain in position with a broad flannel roller, secured with 
safety-pins. Renew every four hours or oftener. The poultice should not exceed 
half an inch in thickness. Caution is necessary in poulticing the chests of infants, 
in order not to overload the chest and tire out the respiratory muscles. 



MUSTARD POULTICES. 

These may be made in a similar way to the above, the mustard being mixed 
with warm water, and stirred well into the linseed poultice. One part of mustard 
to three or four of linseed meal may be used for infants and young children, kept on 
for four hours, and repeated according to the amount of redness produced. 

BRAN POULTICES. 

Bran poultices are preferable to linseed poultices when the weight of the latter 
is an objection, as in colic. A flannel bag is filled with bran, boiling water is then 
poured over it till it is thoroughly saturated ; it is then wrung dry in a towel, placed 
against one's cheek to test the temperature, and applied. 

HOT FOMENTATIONS. 

Flannel or spongio-piline may be used, being wrung out of boiling water in a 
towel, sprinkled with laudanum or turpentine according to the effect desired, and 
applied. The fomentations should be retained in position by means of a flannel 
bandage. 

ANTIPYRETIC METHODS. 

Sponging. — The readiest means of reducing temperature when the fever is 
moderate in degree is by sponging. The child should be stripped and lie upon a 
blanket or sheet with a waterproof beneath ; a large sponge should be used, and the 
face, trunk, and extremities sponged for five or ten minutes. The water used 
should be cold, but with nervous patients it is well to begin with tepid water. If 
the child is feeble it may have a hot bottle to its feet during the sponging. Cold 
sponging is a useful and safe means of reducing temperature in all febrile conditions, 
but its action is only temporary. 

Packs. — The efficacy of a continuous pack in reducing temperature depends 
upon its action on the skin in producing sweating, the cooling effect of the applica- 
tion of the wetted sheet being temporary only, unless frequently reapplied. Packs 
are most useful in conjunction with certain drugs, as aconite and quinine. To 
apply a cold pack a sheet should be wrung out of cold water and applied to the 
patient from the neck to the feet ; a blanket is then wrapped around the sheet. It 



Appendix 80 1 

■should be reapplied in a quarter of an hour if the temperature appears high, but 
frequently the patient goes to sleep in the pack, and it may be wise to leave him 
undisturbed, for an hour at least. Cold packs are often of great service in scarlet 
fever, measles, and other febrile conditions. In pneumonia packs are often useful, 
the wet sheet being applied only round the chest. 

Baths. — The cold or graduated bath is the most rapid means of reducing a high 
temperature, and has the advantage of being readily applied. The child may be 
placed in a bath of ioo° F. and the temperature of the bath reduced by the gradual 
addition of cold water. The cold water may be poured over the patient's head if 
the temperature is high. Cold baths may be used in enteric, pneumonia, measles, 
indeed in a high temperature from any cause excepting scarlet fever or diphtheria. 
In severe attacks of these diseases the cold bath is apt to depress too much, the 
patient becoming cold and collapsed. 

Enema. — Enemata of cold water have been successfully used in reducing tem- 
perature, but can only be of limited application. 

Ice-bags. — Ice applied to the head or chest in a rubber bag, or flannel wrung 
out of ice and water, form effectual means of reducing temperature. 

Aconite. — Given in the form of tincture, is useful as an antipyretic in conjunc- 
tion with packs. It is necessarily of limited application on account of the depres- 
sion it produces if pushed. A quarter to one minim may be given every hour in 
pneumonia, the effect being carefully watched. 

Quinine. — Quinine may be given to reduce temperature in doses of two to ten 
grains of the sulphate in syrup of orange-peel, milk, or cocoa ; it is useful for this pur- 
pose in conjunction with packs in malaria, scarlet fever, pneumonia, and measles. 
If given by the rectum, the neutral bisulphate should be used, or the sulphate 
should be dissolved with the least possible excess of acid. It is well to bear in mind 
that it is useless to expect absorption from a rectum loaded with faeces, and a 
drachm of glycerine must be administered in order to relieve the bowels before in- 
jecting the quinine. The quantity given by rectum must be double that given by 
mouth. 

The subcutaneous injection of quinine is not often resorted to in infants, inas- 
much as a neutral solution is not often at hand when wanted. In a high tempera- 
ture due to malaria it would be of service. 

Antifebrin. — This drug is much used at the present time in reducing high 
temperatures. It maybe given in the form of powder ; or in wine, as it is insolu- 
ble in water. It is better to begin with a small dose and to repeat every three or 
four hours if necessary. One-grain doses may be given under two years of age, two 
grains from two to four years of age, three to four grains for older children, and 
repeated if necessary every four hours. An overdose is apt to produce cyanosis, 
weak pulse, and profuse sweating. This drug is useful in acute pneumonia, measles, 
typhoid, and scarlet fever. The continuous use of it should be avoided if there are 
any symptoms of cardiac failure; toxic symptoms, especially jaundice and albumi- 
nuria, may arise. 

Antipyrine. — This drug is used in a similar way to antifebrin ; the dose given 
must lie twice as large to produce the same effect. 

Phenacetin is another drug of the same series, and nun be given in doses of the 



802 Diseases of Children 

same size as antifebrin. This is much preferred in the United States to other 
drugs of its class, as being safe and equally effective. 

HOT PACKS. 

Hot packing is most useful in nephritis, especially when the kidneys are choked. 
A blanket is wrung out of hot water as dry as possible and quickly applied, care 
being taken that it is not too hot; it may be renewed in half an hour. 

HOT AIR OR VAPOUR BATHS. 

These are useful under similar circumstances to the hot pack ; they are best ap- 
plied by means of a special apparatus, Allen's being the best. A hot vapor bath 
can be improvised for a child with a 'bronchitis kettle,' or even an ordinary ket- 
tle, and spirit or paraffin lamp, a chair being used as a ' cradle.' There is, how- 
ever, some risk of accident. 

MUSTARD BATH. 

An ounce of mustard to a gallon of water (ioo° F.) is the right proportion. The 
mustard should be made into a paste in a basin, and gradually stirred into the 
water of the bath. Useful in diarrhoea, pneumonia, or collapse from any cause ; 
more especially in infants and young children. 

NARCOTICS. 

Opiates. — Infants are sensitive to the action of opium, and this drug requires 
to be administered with great caution and its effect carefully watched. At the same 
time there cannot be a doubt as to its value in many instances, particularly in reliev 
ing pain and quieting the overaction of the bowels. In prescribing it to infants, 
not only the question of age, but also the size of the child, and the complaint from 
which it is suffering, and the degree of exhaustion present, must be borne in mind. 
It is obvious that the dose of opium suitable for a strong, well-nourished infant of 
six months of age, suffering from colic, might be unsafe if given to an infant of 
eighteen months in the last stages of gastro-intestinal atrophy. Infants in the last 
stages of diarrhoea, atrophy, and pneumonia are exceedingly sensitive to opium, 
and caution should be observed in giving it to them. Moreover, such infants pass 
sometimes into a comatose state before death, not unlike the condition produced 
by opium poisoning, and under these circumstances the immediate cause of death 
might be attributed to opium. As a general rule, and presuming the infant is a 
well-nourished one, \ grain of Dover's powder may be given to an infant of six 
months and repeated in four hours if necessary. Larger doses may be given with 
safety if the infant can be watched, and indeed, if the infant is suffering from acute 
colic or intussusception, twice or even four times the dose named may be given. 
In one case coming under our observation, -} s grain of acetate of morphia was given 
to a strong infant four months of age suffering from acute abdominal pain ; the 
infant became drowsy, the pupils were semi-contracted, it remained in a semi- 
comatose state with sighing respiration for two or three hours, when it woke up 



Appendix 803 

perfectly well. It was evident, however, that the limit of safety had been passed. 
Three grains of pulv. kino co. (Br.) were given to an infant of six months, who was 
much wasted and suffering from diarrhoea, at intervals of four hours, three doses 
being given in all. The second dose made it drowsy ; it died a few hours after the 
third dose, with all the symptoms of opium poisoning. It had taken in all nearly 
\ grain of opium. One grain of Dover's powder, or a minim (= T in grain) of liq. 
morphia, is an average dose for on infant a year old, and may be repeated in two 
or four hours if necessary. Two or three grains of Dover's powder, or two or three 
minims of liq. morphinse, may be given to children between two and four years of 
age. Children over six years of age are much less sensitive to opium than younger 
children, and \ to \ grain of opium may be given if necessary to relieve pain in 
peritonitis or other diseases. It must be borne in mind that idiosyncrasies may be 
met with, and infants may be found exceedingly sensitive to opium, or, on the 
other hand, very tolerant. 

Subcutaneous injections of morphia are best avoided in infants under a year, and 
are not often required for young children ; - 5 L u grain would be a full dose for an 
infant of a year. 

Codeine is of some value in relieving pain in children, especially in connection 
with the alimentary system. It may be given in syrup of orange. It may be given 
in doses of -f^-d grain to infants and young children, and \~\ grain to older chil- 
dren. It is useful in colic, diarrhoea with tenesmus, and irritative cough — in the 
latter perhaps not so good as morphia. 

Chloral hydrate. — Chloral is soluble in water, and maybe given 2 or 2^ grains 
to the drachm of cinnamon water, sweetened with syrup of orange. Infants and 
children tolerate chloral well ; its principal use, combined with bromide, is in 
convulsions and to procure sleep. It is of but little use in relieving pain. 2-J-- 5 
grains may be given to children from a year to two years old. 5-10 grains may be 
given to older children. Very much larger doses have been given to procure an- 
aesthesia (Bouchut). 

Bromide of potassium. — 2-2-J grains to the drachm of water sweetened with 
syrup of orange or lemon, and spirit of chloroform. The liquid extract of liquor- 
ice hides the taste fairly well. 3-5 grains may be given to children from a few 
weeks to two years of age, and repeated every two hours if necessary. 20-60 grains 
a day may be given to older children who are suffering from cerebral excitement or 
fits. There is little risk in an overdose ; children well under the influence of bro- 
mide are lethargic, speak with a slow drawling tone, and suffer from acne. 

Antipyrine acts as a sedative in small doses in infants and young children ; 
\-\ grain may be given to infants suffering from colic or painful dentition. 

Belladonna and atropine are much used in whooping-cough, incontinence of 
urine, and as external applications. Children are tolerant of these drugs, and 
larger proportional doses than those given to adults may be prescribed, if they are 
carefully watched. Children of one to two years of age may be given 1-3 drops of 
the tincture every four hours. Older children, 2-7 minims or more, though it is 
wiser to begin with minimum doses and gradually increase the dose. Atropine is 
more dangerous, and is best avoided in young children. Children five years old 
and upward may be given minim doses ( M l , (1 grain) of the liquor, cautiously in- 



804 Diseases of Children 

creased. Temporary excitement and dilated pupils are the result ::' an over- 

f : ::. 

Cannabis indica. — Children bear this drug well ; it is usefully added to bromide 

in 2~ auir.im :: :: ml a: a f ;ses ::' ±r :in_:ure in aa-_ : . ;".. 

Hyoscyamus — 7:a::are :: hy.sryamas is asea as : a ia:ayae ia ala:e ::' 
opium. Its nauseous taste is one objection to it ; it may be given in 5 -minim doses 
:: ia infau: 1 yea: :1a. ::-:: mia.ms :: :1 ier hail area. 

Hyoscyamine sulahare :s f:e:aeahy ^:ls:::;:t: f:r ahe ::a::are 
atropine, it must be used cautiously, or not given at all to infants, ^oo g*"-» ca* 1 - 
tiously increased to J$ gr., may be given to older children ; larger doses have been 

Hyos cine aaay : = r - :iu:i: a ::: hue same a:ses is a: :ve. :u: is said :: 

1 e a :re a::ive. 

PURGATIVES AND LAXATIVES. 

Mercury inf. chalk ly hself. :r in c:u .... rhu'carl: ana s: 

verymhe : nearly r^ven as a lauiaive : : in: an as a fe— m ahas :lf. : — hen the s:: :1s 
inaiaare s:ane irrr.ahve tamers ia :he ": :vrels. 7:r this aura : se 4-2 ~rs. a 
.riven :~;;e a fay :':r a fe~ - r :':: ; :r three sutcessi re nights. 

Calomel :s a referable f : :1 ie: hail area a a::: an: ::' he smaller f :se re: 
i: may le :/:.. —1th - . aymin rhular:. s:amm:ay. :r alamae. A ram.:, 

may :e ryvea v::h "hn-r raga: :: a :hha ■::' :ae :: :hree years half a grain :: an 
:afan: ::" -a: m:n:hs. is zaargauve. Half :he tuaatl:-. may 1 e a." e: . ■ ::h ::her 
drugs ; thus — calomel, gr. ^ ; scammony resin, gr. £ ; calomel, gr. ^ ; pulv. rhei, gr. 
4-: state gr. 4 aael rr. 4-: eaiaymfa. nr. -. 5 a: ill aihales 

calomel, gr. £;ex. colocynth. 00., gr. \ ; calomel, rr \ -v. ha:., r - ansi 
welh S:me a refer :: are small f:ses :f :nis Irug. as rr. r. reteatea every tttur 
rlll :he 1 :— els 1::. 

Rhubarb f:rm= : safe aaf a : a-irrrharlve aargahve. aaf is esaetially useful ia 
combination with 4 soda when a laxative and stomachic is required. It unfortunately 
has a nauseous taste, best covered by syrup of orange or spirits of nutmeg. Tab- 
l;ias : rheum :. s: la ire very ::nveaiena 

The syrup is a good preparation, especially in combination with an equal quan- 
rlay : : a : :: senna. :f — hi;h half a tea-sat taful : : a sa : taful is z arse. " Misu 
rhei 00.* is much used as a laxative, given two or three times a day, especially in 
iufaa-.s —hen :he s:: :1s are • autty-lake ' mf = rar-smelltag . :hus. syrua. rhei, ~yo: ; 
soda? bicarb., gr. j ; aq. menth. pip., 3 j. 

Inf. rhei with soda? carb. and sp. ammon. aromat. forms a useful carminative 
for infants — such as sp. ammon. aromat., TT iii ; sodse bicarb., gr. ii ; syrup, zingib., 
inf. rhei ad 3j; sp. ammon. aromat., TT^iiss ; syrup, zingib. li^xx; inf. 
rhei, TH^xv; inf. gent. co. ad 3 j. 

Ate: — er la :he f:rm ::' the : :. e 

in pilules. Small pilules containing -$■ grain of aq. ext. of aloes are readil v s 
lowed by children, or they can be divided with a knife and given in jam. Aloin is 
useful in treating the constipation of infants and young children ; ' anticonstipa- 
tion' * tabloids, 1 containing aloin, gr. ^, belladonnas ex:., rr -t. strychnine, gr. ^ 



Appendix 805 

ipecac, gr. -fe, may be used, half a one being given to infants once or twice a day, 
mixed with a little white sugar. 

Senna. — Mostly given in the form of the compound liquorice powder, syrup, or 
infusion. The former is much used as a household medicine, quarter to one tea- 
spoonfuls being given mixed with a little water. The syrup is pleasanter to take, be- 
ing free from any grittiness ; a tea-spoonful is the usual dose ; it is most effective 
when given with an equal quantity of syrup of rhubarb. The infusion is given in 
constipation with some bitter, as strychnine or calumba, such as liq. strychnise, 
TT^ss ; glycerine, TT^x ; inf. sennas, TT[_xx ; inf. calumbae, ad 3 j, b. or t. d. s. Old 
preparations of senna are apt to gripe. 

Cascara sagrada is of much value in habitual constipation in infants and chil- 
dren. It may be given in syrup or some of the elixirs, chocolate bonbons or loz- 
enges. Some chemists prepare an extract from which the bitter principle has been 
removed. Five to 20 minims of the liquid extract once a day is the usual dose. 

Podophyllum resin may be given in powder or ' tabloid ' form to infants and 
children suffering from constipation, beginning with -}-$ g r - to -fa gr. two or three 
times a day. Liq. podophylli (gr. \ ad 3 j), made by some chemists, is a useful 
preparation, and may be prescribed with strychnine, bitters, acids, or alkalies. 

Rubinat, Hunyadi Janos, Carlsbad mineral waters — a table-spoonful or 
more in warm water or milk, given before breakfast — are very useful purgatives for 
children over four years of age. 

EMETICS. 

Pulv. ipecac, is the best and safest emetic for children. It may be kept in 
the form of powder or the 5 grain ' tabloids.' Five grains may be given, and re- 
peated every ten minutes till vomiting is produced, to infants and young children. 
Ten grains may be given in one dose to older children, and repeated in ten minutes 
or a quarter of an hour. There is great difference in children with regard to the ease 
with which they are made to vomit. In the later stages of croup or pneumonia. 
when the face and lips are pale or bluish, it is difficult to excite vomiting ; indeed 
at this stage emetics are useless. 

Apomorphia is apt to depress too much ; it may be given ^—h g r - subcutane- 
ously, but not to infants. 

Alum. — Half a tea-spoonful in honey or syrup is useful in whooping cough. 

EXPECTORANTS AND DIAPHORETICS. 

Ipecacuanha is usually given in the form of vinum ipecac, in doses of T^iiss- 
%y to infants up to a year old, TT^v-TT^xv to older children, repeated every two to 
four hours. It may be given with T^v-x of aq. laurocerasi and TT^x of glycerine to 
the drachm of water; or syrup pruni virgin, may be added. Yin ipecac, is apt to 
lose- its strength by keeping. 

Pulv. ipecac, co. is a useful expectorant (see Opium). 

Antimony. — Mostly given as vinum, in the same doses as vin. ipecac; often 
prescribed with mist, amygdalae. Both ipecac, and antimony are better given in 
small doses, frequently repeated, than in increasing doses. In acute bronchitis or 
laryngitis it is often useful to push either ipecac, or antimony freely till sickness is 



806 Diseases of Children 

produced, then to lessen the dose. Both these drugs are given in the early stage 
of bronchitis when rhonchi and sibilus are heard. 

Emetine. — Dose too— tV S r - '■> not often prescribed. 

Liq. ammon. citratis or liq. ammon. acet. is of ten combined with vin. ipecac, 
or vin. antimon. in doses of T^xv-Tf^xx for infants up to a year, 3 ss to 3 j for 
older children, well diluted, with syrup tolu, aurant., or pruni virgin, to cover 
the taste. 

Sp. ammon. aromat. — Dose TT|_ii — TT^iii in a drachm of syrup or glycerine and 
water for infants ; TT^iv-T^x, well diluted, for older children. 

Ammon. carbonat. or chloride. Dose : gr. iss-gr. v, well diluted, and dis- 
guised as far as possible by syrup aurant., tolu, or scillae. 

Squills. — Useful as a stimulating expectorant in bronchitis, when the secretion 
is free, fluid rales being heard in the chest, and but little being coughed up. Tinc- 
ture : doses TT[ii-Tf[iii for an infant up to a year old ; TT^iii-Ti^v for older children, 
repeated every four hours. Syrup or oxy-mel : lf[x- 3 ss. The syrup is often com- 
bined with ipecac, or ammonia, according to the stage of the bronchial affection. 

Terebene. — Often useful as a stimulating expectorant; not often given inter- 
nally to infants. TT^ii to TT[v may be given on sugar to older children, or suspended 
in mucilage and syrup of lemon. 

ANTACIDS AND CARMINATIVES. 

Alkalies and aromatics are frequently required in the dyspepsias of infancy. Of 
the former, sodas bicarb, gr. iiss, magnesias carb. gr. iii, combined with syrup 
zingib. and aq. anisi ad 3 j, is useful ; or sodas bicai-b. gr. iiss, tr. nucis vomicae, 
Tf^-J, tr. cardamom, co. Tf^v, sp. chloroformi, TT^iiss, aq. anethi, ad 3 j, given occa- 
sionally. 

TONICS. 

Cod-liver oil takes the first place. It is best given after meals and in the form 
of an emulsion ; some of the latter are to be obtained combined with lime salts. 
1T\x to Tf^xx of the cil twice or three times a day is the dose for infants ; 3 ss to 
3 j may be given to older children. Dyspepsia, catarrh of intestines, and diarrhoea 
should be treated before cod-liver is given. Inunctions of warm cod-liver are often 
useful ; the oil is applied on a sponge and the child clothed in a flannel nightdress. 

Acids. — Dilute nitric acid (Tf^iss to H\_ii, aq. ad 3 j) is often of much service dur- 
ing convalescence. It may be combined with tr. cinchonas co., or decoc. cinchonas 
and syrup limonis. 

Iron. — Often given as vinum ferri, IT^x to 3 j, syrup ferri phos. co. TT^x to 3 j, or 
tr. ferri perchlorid. Tf|_i to TT^ii, in a wineglass of water at meal times. Ferri et 
ammon. cit. may be combined with alkalies and mix vomica. 

STIMULANTS. 

Alcohol necessarily takes the first place in the list, and is beyond all question 
of value in treating acute disease when there is evidence of a flagging heart. It is 
not a matter of much importance what form of alcohol is selected, presuming it is 



Appendix 807 

of good quality. Brandy, in the form of mist. sp. vini gallici, *is the one perhaps 
most generally useful. In hospital whiskey frequently takes the place of brandy 
for the sake of economy. Curacoa, champagne, port wine, more or less diluted 
according to circumstances, may be used. Alcoholic stimulants are called for in 
the adynamic forms of scarlet fever, diphtheria, broncho-pneumonia, acute diar- 
rhoea, and other allied conditions. The pulse is the best guide : a feeble, irregular, 
intermittent pulse calls for alcohol, mere rapidity of pulse does not. Drowsiness, if 
it does not contra-indicate alcohol at least calls for caution in its administration, 
as overdosing with alcohol is apt to make the drowsiness more pronounced, espe- 
cially that form due to a hypervenous condition of blood. Delirium is often made 
worse by alcohol, especially if there is evidence of cerebral congestion, the con- 
junctival vessels being injected as in the early days of scarlet fever. In such cases 
opium or bromide answers better. Vomiting is a signal for discontinuing alcohol, 
for a while at least. Unfortunately champagne, so useful as a rapidly diffusable 
stimulant, is apt to produce sickness. The amount of alcohol given necessarily 
depends upon circumstances : drachm doses of brandy, or even more, every hour, 
may be given in some cases of scarlet fever or broncho-pneumonia, with advantage 
even to young children. In infants alcohol is principally of value in colic and acute 
diarrhoea, and may be given well diluted with barley water, arrowroot, or milk. 
Port wine sometimes seems to agree better than spirit. In chronic disease alcohol 
is of less value than in acute, as the long-continued administration of it certainly 
has its evils, and is apt to produce dyspepsia and sluggish liver. In anaemia, scro- 
fulosis, and tuberculosis the wine of St. Raphael, port wine, or porter may some- 
times be given with advantage. [Also see Heart-stimulant, under Pneumonia, p. 

725-] 

FORCED FEEDING. GAVAGE. 

Difficulties sometimes arise in feeding immature infants and those with cleft 
palates, the infant being too weak to suck ; or the conformation of the mouth may 
render this impossible. In diphtheria, when the tonsils are enlarged and painful, 
or in paralysis of the pharynx, ' forced feeding ' may have to be resorted to. For 
weakly infants the * fountain ' feeding bottles have been devised, and the ' bibe- 
rons pompes ' of the French ; there is, however, no difficulty in feeding a weakly 
infant by means of the ordinary boat-shaped feeder if held slightly inclined. In- 
fants with cleft palates have to be fed by spoon or by means of the ' Scott-Battams 
method,' namely, a piece of india-tubing attached to a glass syringe. In difficulty 
of swallowing from any cause this last method is the most generally useful. An 
ordinary glass syringe is taken and filled with milk, beef-tea, or other liquid nour- 
ishment, a piece of india-rubber tubing a few inches long is attached, the latter is 
passed into the mouth to the back of the tongue, and the piston of the syringe slowly 
pressed from time to time, so that small quantities of fluid are swallowed from time 
to time. The tube need not be passed between the teeth ; if the latter are clenched 
the tube may be passed between the cheek and the jaws. In eases where the pha- 
rynx is completely paralysed a medium-sized india-rubber catheter must be passed 
through the nose into the pharynx and oesophagus, and food introduced into the 
stomach. 



8o8 Diseases of Children 

Forced feeding has also been used by Dr. Kerley, of New York, in cases of per- 
sistent vomiting in young infants, his experience being that food introduced 
directly into the stomach by a tube and funnel is less readily rejected than if 
swallowed in the ordinary way. His method is as follows : The infant is held in a 
half reclining posture on the nurse's right arm ; a soft india-rubber catheter, at- 
tached to a funnel of three or four ounces capacity by a rubber tube two and a half 
feet long, is rapidly introduced into the stomach, a half to two and a half ounces 
of liquid food introduced into the funnel ; the latter is then raised and when empty 
rapidly withdrawn. This method of forced feeding appears to be more successful 
in infants than in older children. A preliminary stomach washing should precede 
the first forced feeding. 

STOMACH WASHING. 

Washing out the stomach is often a highly beneficial proceeding in the dyspep- 
sias of infants, especially when vomiting of decomposing curd is a prominent symp- 
tom. The removal of curd which may have remained in the stomach for some days, 
as well as the acid mucus, is certain to be beneficial. The method of carrying it is 
the same in infants as in adults. An india-rubber catheter as large as possible is 
passed down the pharynx into the stomach, and connected by means of an india- 
rubber tube, two or three feet in length, with a funnel. One or two ounces of 
warm two per cent, solution of borax is introduced into the tunnel ; the latter is 
raised so that the fluid flows into the stomach, and then lowered and inverted so as 
to allow of the return of the fluid contents of the stomach. This proceeding is 
repeated till the returning fluid is clean and sweet. Curdy material often escapes 
by the side of the tube. 

Stomach washing is useful not only in the chronic dyspepsias of infancy, but 
also in the vomiting of acute gastric catarrh and other forms of vomiting. 



ENEMATA. 

Enemata are required for various purposes during infancy and childhood. A 
simple enema may be required to unload the bowels and clear away scybala which 
have collected in the large bowel ; or they may be given for other purposes, such 
as that of applying local treatment to the mucous membrane of the colon, to re- 
place an invagination, or to destroy oxyurides which are present there. Rectal in- 
jections are also resorted to as a means of administering drugs or nutriment. 

Purgative enemata are generally given with a fountain syringe, and at a temper- 
ature of about ioo°. They may consist of soap and water with the addition of 
olive oil, castor oil, or turpentine. When the latter is used a teaspoonful of ol. 
terebinth., two teaspoonfuls of olive oil, and the yolk of an egg may be shaken up 
with four or five ounces of water for a child of two or three years. A large quan- 
tity of fluid may be injected if the fluid is required to reach the upper part of the 
large bowel. Some care is required, in giving an injection, to do it slowly, avoid- 
ing all force. If it is required simply to unload the lower bowel, an injection of a 
teaspoonful of glycerine is all that is required. Enemata for the destruction of the 
oxyurides are best given after a sharp purgative has been administered, in order to 



Appendix 809 

drive the parasites as much as possible into the lower part of the intestines. For 
this purpose the turpentine injection referred to above answers very well, or half a 
pint to a pint of corrosive chloride of mercury (i to 2, ooo) maybe used. Re- 
peated ' irrigation ' of the large bowel has been much practised on the Continent 
{Monti, Baginsky) in various diseased conditions, such as constipation, dysenteric 
diarrhoea, catarrh of the large bowel, &c. Large quantities of water or various 
solutions are injected by means of an india-rubber tube with a nozzle to fit in the 
rectum, and a funnel. The forcing of a large quantity of fluid into the colon, es- 
pecially in young children, is not always easy, on account of the straining and 
struggling which it is apt to produce, and forcible injection of fluid by means of 
raising the funnel with tube attached is not free from danger. In irritable condi- 
tions of the colon warm mucilaginous fluids, such as decoction of arrowroot, two 
to four ounces, with two to five minims of laudanum, is soothing, and relieves tenes- 
mus. The subnitrate of oxide of bismuth, suspended in mucilage, and three or 
four ounces injected, is also useful. In more chronic cases, alum, zinc, sulphate, or 
nitrate of silver may be used. On the whole, opiates are the most comforting to 
the patient. 

Nutrient enemata may be given of peptonised beef-tea, or milk with brandy, or 
some other form of alcohol. 



DIRECTIONS FOR USE OF DISINFECTANTS. 

Solution A. — Chloride of lime, eight ounces; soft water, one gallon. 

Solution B. — Liq. sodse chlorinatse, one part ; soft water, five parts. 

Solution C. — Corrosive chloride of mercury, four ounces ; permanganate of 
potash, one dram; soft water, one gallon. 

Stock bottles to be kept locked up, and labelled ' POISON.' 

For use : — one fluid ounce to be mixed with one gallon of water. 

Use of A. — For the disinfection of excreta : Mix well with each stool half a 
pint of solution A, and allow it to stand for ten minutes before emptying it into the 
closet. Treat the vomit of fever patients similarly, and keep the sputa-cups of 
phthisical patients half full of the same solution. 

Use of B. — (i) For the washing of hands and the cleansing of spatulas, ther- 
mometers, and other infected instruments ; (2) for the thermometers to be kept in ; 
(3) for the sponging of those dying of fever, previous to their removal to the mor- 
tuary ; (4) diluted with four times its bulk of water, for the daily sponging of fever 
patients. 

Use of C. — For the disinfection of clothes : The clothes to be soaked in the 
solution for two hours, in an earthenware vessel, before being sent to the wash. 

To Disinfect a Room. — Tightly close all windows, fire-places, and ventila- 
tors. Moisten powdered sulphur with spirit, place it in a shallow iron pan sup- 
ported on a couple of bricks in a bowl of water ; light it, and keep the room closed 
for ten hours. Three pounds of sulphur must be used for each 1,000 cubic feet of 
airspace. N. B. — 5 lbs. is necessary for each special ward. Then open all win- 
dows, &c. , and wash the floors, walls, furniture, &c, with the following solution : 
Solution C, four fluid ounces ; water one gallon, taking especial care to thoroughly 



Sio Diseases of Children 

wash out all dust from window-ledges, corners, Szc. Allow free ventilation for 
:y-four hours. 

LOEFFLER'S D-BACILLUS. 

A sznall piece of membrane, exudation, or mucus is broken up or smeared over 
a covered glass, and the latter dried by passing it several times through the flame of 
a spirit lamp, taking care not to overheat. A few drops of a solution of Loeffler's 
potash-methylene blue are placed on the dried exudation for five minutes ; the 
cover glass is then again dried, a drop of balsam placed on it ; it is then placed on 
a glass slide and examined with a -jV oil immersion. The D-bacflU may usually be 
recognised by the characters already given (p. 266). It must be admitted, however, 
their morphological characters are often not decis: we. 

Cultivations on blood-serum and injections of the medium used for cultivations 



Appendix 



FORMULA 



The doses given are suitable for an infant of a year old unless otherwise stated. 



DISORDERS OF DENTITION, p. 58 

(1) 



Potassii bromidi . . . gr. iiss 


Chloralis .... 


gr. U 


Tr. hyoscyami . . . ttj, v 


Potassii bromidi 


gr- ij 


Ext. glycyrrh. fl. . . tt^ x 


Sp. ammon. aromat. 


TTlij 


Aquae . . . q. s. ad 3 j 


Syrupi pruni Virg. 


TTl X 


Every two or three hours, for an infant 


Aquae . . . . q. s 


ad 3 j 


of seven months. 


Every two or three hour. 
(2) 


r. 


Antipyrini . . . gr. j 


Hydrargyri chlor. mit. . 


gr. ss 


Elixir aromat. . . . Tf[ v 


Euonymin .... 


gr. ss 


Aqua? . . . . q. s. ad 3 j 


Sacchari .... 


gr. ss 


Every two hours till relieved. 


The powder at night. 
(3) 




Sodii boratis 


3 ss 




Tr. myrrhae 


3 ss 




Glycerini 


• 3j 




Aq. rosae . 


• • 3J 




To be painted on the gums or aphthous patches. 





CATARRHAL STOMATITIS, p. 60 



Potassii chloratis . 
Syrupi aurantii 
Aquae . . . . q, 
Three times a day. 



(4) 



Acidi borici 
Sp. thymol . 

Glycerini 
Aquse . 



(r-10) 



gr- j 


Potassii chloratis . . gr. j 


TFl XV 


Ext. cinchona; fl. . . . V\ v 


ad 3 j 


Elixir aromat. . . . 1f l v 




Aquae . . . . q. s. ad 3 j 




Three times a day. 


gr. x 


Sodii bicarb. . . 3 j 


111 V 


Sp. thymol . . . • 3 j 




Glycerini . . . 3 ij 


3 ss 


Aquse . . q. s. ad ; \ iii 


• & d 5 j 


As a mouth-wash for children. 



To be painted on the aphthous patches. 



12 



Diseases of CJiildren 



ACUTE TONSILLITIS, p. 69 



Tr. aconiti . . . . Vi[ j 
Liq. ammon. citratis. (Br.) . 3 j 
Syrupi aurantii . . . TT[ xx 

Aquae . . . . q. s. ad 3 ij 
Every three hours, for a child of five 
years. 

Iodi . . . . gr. iij 

Potassii iodidi . . . 3 j 

Glycerini . . . q. s. ad § j 

Pigment for enlarged tonsils. 



Sodii salicylates . . . gr. v 
Potassii citratis . . . gr. v 

Syrupi pruni Virg. . . . ill xx 
Aquae . . . . q. s. ad 3 ij 
Every three hours, for a child of five or 
six years. 



q. s. 



gr. nss 
ad 3 j 



Magnesii carb. 

Rhei 

Syrupi zingiberis 

Aq. menth. pip. 

Every two hours, for an infant three or 

four months old. 
{y\,\ — TT[j of nepenthe may be added to 

each dose if the infant is under close 

observation.) 



Aluminis . . . 3 ij 

Acidi tannici . . . 3 ss 

Glycerini . . . § ss 

Aquas rosae 

Pigment for ejilarged tonsils. 

FLATULENCE AND COLIC, p. 79 

Chloralis ... g 

Aq. laurocerasi. (Br.) 
Syrupi pruni Virg. . 
Aquae . . . . q. s 
Every three hours. 



q. s. ad 3 ij 



gr. nss 

mx 

ad 3 j 



Sodii bicarb. . 
Sp. ammon. foetid. (Br.) 
Sp. chloroformi 
Aquae anethi. (Br.) . 

Occasionally. 



q. s, 



gr. iiss Hydrargyri cum creta . . gr. \ 

1T[ ij Pulv. ipecac et opii . . gr. i 

TT[ j Sacchari . . . • gr- i 
ad 3 j Ft. pulv. 



Sodii bicarb. 

Aq. laurocerasi. (Br.) . 

Sp. chloroformi 

Aq. anethi. (Br.) . 

Evety four hours. 



(5) 
VOMITING, p- 81 

gr. iiss Liq. bismuth et ammon. citr. (Br.)iTiv 
ttl x Tr. nucis vomicae . . . ttl ss 

, ttl j Glycerini . . . . . ttl x 

ad 3 j Aq. carui. (Br.) . . . ad 3 j 

Every four hours. 



SIMPLE DIARRHCEA, p. 83 



(6) 



(7) 



Ol. ricini 


. TU XV 


Sodii bicarb. 




■ g r - J j 


Acaciae .... 


. gr. v 


Bismuth, subcarb. . 




. gr. iss 


Syrupi zingiberis 


. m v 


Tragacanthae 




• g r - j 


Aq. menth. pip. 


• ad 3 j 


Sp. chloroformi 




. "H, iiss 


Every two hours. 




Aq. cinnamomi 

Every four 


hours. 


. ad3j 



Appendix 



813 



(8) 



Zinci oxidi 




. gr. iss 


Tragacanthae . 




• gr. J 


Sp. chloroformi 




• *lj 


Glycerini 




. TU XV 


Aq. anethi 




• ad3j 


Every four 


hours. 





(9) 

Acidi nitrici dil . . . TT[ j 

Syrupi aurantii . . . ITJ, x 

Decocti granati radicis. (Br.) q.s. ad 3 j 
Every four hours. 



Acidi sulph. aromat 
Magnesii sulphatis 
Ferri sulphatis 
Sp. chloroformi 

Aquae 



. Tit J 

3 ss 
• gr. i 

. Til v 

q. s. ad § ss 
Two or three times a day before meals, 

for a child of ten or twelve years. 

(Burney Yeo.) 

Tr. belladonnas 

Tr. nucis vomicae 

Syrup, sennae . 

Inf. gentianae co. (Br.) . 

Three times a day, for a child of three 

or four years. (Eustace Smith.) 



Acidi hydrocyanici dil. . 
Sp. chloroformi 
Aq. aurantii flor 

Every three hours. 



(10) 

Acidi nitro-hydrochlorici dil. TTJ j 
Liq. peptici . . . tti xx 
Sp. chloroformi . TT^ j 

Aq. aurantii flor. . . ad 3 j 
Three times a day. 

CONSTIPATION pp. 85 and 781 

(11) 

Podophylli 



gr- t 

gr- i 
gr- j 



Euonymin 

Ex. cascara sag. 

In Palatinoids (Oppenheimer) one or two 

a day, for a child of six to twelve years. 



TTl V 


Ex. cascara sag. liq. 


. TTl V 


TTli 


Tr. belladonnas 


. TTl V 


m x 


Elixir aromat . 


. TTl X 


ad3j 


Aquae 


. q. s. ad 3 j 


if three 
VSTRK 


At bedtime. 
3 CATARRH, p. 85 




1T IJ 


Sodii bicarb. . 


. gr. x 


^j 


Aq. laurocerasi. (Br.) 


. TTl xv 


ad3j 


Aq. aurantii flor 


3 ss 




Acidi citrici 


. gr. v 




Aquae 


q. s. ad 3 ij 



The alkaline and acid mixtures to be- 
taken effervescing every four hours, for 
a child of ten or ttvelve years. (Burney 
Yeo.) 



ZYMOTIC DIARRHCEA, pp. 93 and 94 



(12) 

Sodii salicylatis 
01. ricini 




• gr- j 
. TtL xv 


(13) 
Moschi .... 

Acaciae .... 




• gr.i 

• gr- V 


Acaciae . 




. gr. v 


Elixir aromat. 




. HI V 


Syrup, zingiberis 
Aq. menth. pip. 

Every two 


• q- 

hours. 


. TTl v 

s. ad 3 j 


Aq. rosae 

Every two houn 


q. 


s. ad I i 



14 



Diseases of Children 



Bismuthi salicylates 
Sp. ammon. arom. 
Pulv. tragacanth. co. 
Sp. chloroformi 
Aq. carui. (Br.) . 



(Br.) 



Every three hours. 



. m ij 

• gr« J 
. %j 

s. ad 3 j 



Salol gr. ij 

Pulv. tragacanth. co. (Br.) . gr. j 
Elixir aromat. . . . Ti| v. 

Aquae . . . q. s. ad 3 j 

Every two hours. 



CHRONIC DIARRHCEA, p. 104 



(14) 



Extracti haematoxyli 


gr. iiss 


Tr. catechu 


TTL V 


Syrupi tolu 


V\ X 


Aq. cinnamomi 


ad 3 j 


Every four hours. 





Argenti nitratis . . . gr. v 
Aquas . . . . . O ss 
To be used as an enema. 



CHRONIC GASTRO-INTESTINAL CATARRH, pp. 105 and 106 



(15) 



Sodii bicarb. . . . gr. ij 

Pepsini gr. j 

Sacchari . . . . gr. j 

Half an hour after meals. 



Acidi nitrici dil. . . . ~ Til iij 

Liq. helaline et pepsin co. . 3 ss 

Sp. chloroformi . . ttl ij 

Aq. aurantii flor. . . 3 iij 
Three times a day. 



Sodii bicarb. .... 
Hydrargyri cum creta 
Pulv. rhei co. ... 

Sacchari .... 

Half an hour after meals. 



gr-i 
gr * 
g r - j 



(16) 



Acidi hydrochlorici dil. . 
Liq. euonymin et peps. co. 

(Oppenheimer) 
Elixir aromat. 

Aquae . . . . q. 
Three times a day. 



. m iij 

3 ss 

. TIJ, XV 

s. ad 3 iij 



{For children of seven to ten years.) 
(17) 



Sodii bicarb. 


■ gr. y 


Potassii bicarbonatis 




• gr- v 


Inf. rhei (Br.) 


. 3j 


Tr. nucis vomicae . 




• mj 


Elixir aromat. 


. Til xv 


Aq. laurocerasi (Br.) 




. Til xv 


Aquae 


q. s. ad 3 iij 


Elixir aromat 




. Til XV 


Three times a day before meals. 


Aquae 


q- 


s. ad 3 iij 



Three times a day before meals. 
{For children of seven to ten years.) 

(18) 
Acidi nitrici dil. . . . tt[ iij 
Ext. cinchonae fl. . . . v\ y 
Syrup, aurantii . . 3 ss 

Aquae . . . q. s. ad 3 iij 

Three times a day after meals, for children of seven to ten years. 



Appendix 



5 



TUBERCULAR ULCERATION OF THE BOWELS, p. 140 

(20) (21) 

Hydrargyri cum creta . . gr. j Pulv. kino co. (Br.) . . gr. i-ij 

Pulv. ipecac et opii . . gr. ij Sacchari . . . gr. ij 

Every night, for a child of Jive years. Every night, for a child of five to seven 

years. 

(22) 
Emuls. ol. morrhuse B.P.C. " Bynol " (Allen & Hanbury). 

One to three teaspoonfuls three times a One to three teaspoonfuls three times a 
day. day. 

Byno-hypophosphites (Allen & Hanbury). 
One to three teaspoonfuls three times a day. 



CATARRHAL LARYNGITIS, p. 191 

(23) 
Antimonii et potassii tartatris gr. <fo Apomorphinae hydrochlor 
Liq. ammon. citr. (Br.) . Til x 

Elixir aromat. . . . . HI v 

Aquas . . . . q. s. ad 3 j 
Every four hours, for a child of two to 
three years. 



Vin. ipecac . . . nx ij 

Elixir aromat. . . . TT[ v 

Aquae . . . . q. s. ad 3 j 

Every four hours, for a child of two to 
three years. 



BRONCHITIS AND BRONCHO-PNEUMONIA, pp. 221, 222, and 223 

Codeinse . . . . gr. \ 

Elixir rubrum . . . TT[ v 

Aquae . . . . q. s. ad 3 j 

Occasionally, for a child of five or six 



years. 



(24) 



Ammon. carb. 


• g r - j- 


Tr. digitalis . 


. . mj 


Syrup, scillae . 


. til XX 


Aq. anethi (Br.) . 


. ad 3 j 



Every four hottrs. 
(26) 



§ss 



Tr. capsici 
Lin. saponis . 

To be applied to the affected part 



ss 



Liq. morphinae hydrochlor. (Br.) tt[ ij 
Acid. nitr. dil. . . tt^ j 

Syrup, aurant. . . . U[ xx 

Aquae . . . . q. s. ad, 3 j 
Occasionally, for a child of eight to ten 
years. 



(25) 



TT| x 



01. sinapis volat. . 

Lin. camph. . . • I j 

To be rubbed on the affected part. 



(27) 
Capsici . . . . 3 j 

Adipis lanae hydros. . • § j 
To be used to the affected part. 



8i6 



Diseases of Children 



Vini ipecac. . . . TT[ ij 
Liq. ammon. citratis. (Br.) TT[ x 
Syrup, tolu. . . . til x 
Aquas . . . q. s. ad 3 j 
Every four hours. 



Potass, bicarb. . 


• gr- j 


Potass, iodidi . 


• gr-i 


Ext. cinch, fl. . 


• fTL ij 


Syrup, scillae 


. TTJ, x 


Aquae 


q. s. ad 3 j 



Antimonii et potassii tartrat . gr. ^g- 
Liq. morphias hydrochlor. (Br.) TIL j 
Aq. laurocerasi. (Br.) . . til x 
Elixir aromatici. . . . til x 

Aquae . . . . q. s. ad 3 ij 
Every four hours, for a child of five to 
six years. 

Sodii bicarb. . . gr. x 

Glyc. acid, carbolici . 3 j 

Aquae . . . q. s. ad § j 
To be used zvith Siegles steam spray. 
(Burney Yeo.) 



Three times a day. 



Liq. strychniae . 
Tr. digitalis 
Sp. chloroformi 
Aq. aurant. flor. 



ACUTE PNEUMONIA, p. 232 

• TTLi 

• TTL ij 



ad 



-J 



Every four hours, for a child of two or 
four years. 



Tr. aconiti 








mj 


Liq. ammon. 


acet 






TIL XV 


Aq. laurocerasi. 


(Br.) 




TTL X 


Elix. aromat. 








TTL X 


Aquae 






q- 


s. ad 3 ij 



Every four hours, for a child of two to 
five years. 



BRONCHIAL ASTHMA, p. 245 



Antimonii et potassii tartratis 
Liq. morphiae hyd. (Br.) 
Potass, iodidi 
Sp. chlor. 

Aquae ... . . q. 

With an equal quantity of water every 

three hours, for a child of five or six 

years. (Burney Yeo.) 



gr 


-h 


TTL 


ij 


gr- 


ij 


TTL 


ij 


ad 


3ij 



Pot. iodidi . . . gr. l\ 

Ext. stramonii . . . gr. fV 

Sp. chlorof. . . . til v 
Sp. ammon. aromat. . TTL v 

Aquae . . . q. s. ad § ss 

Three times a day (Burney Yeo), for 
child of ten years. 



TUBERCULOSIS OF LUNGS, p. 253 



Ol. morrhuae 
Extr. of malt 



3 ss 
ad 3j 



Three times a day. 

Ol. morrhuae . . . 3 j 

Creasoti . . . . TIL i 

Three times a day after food. {Very 
nauseous.) 



" Byno-hypophosphites " (Allen & Han- 
bury). 
One to three teaspoonfuls three times a 
day. 

(27) 
Lin. iodi. (Br.) . . § ss 
Glycerini . . . 3 ij 

Aquae . . . q. s. ad § iss 
To be painted over the affected part. 



Appendix 



8i 7 



Potass, chlorat. 


• gr. v 


Ext. cinchon. fl. 


. TTi v 


Elixir aromat. . 


. TT[ XV 


Aquae 


q. s. ad 3 iij 



SCARLET FEVER, p. 270 

Ammon. carb. . 
Ex. cinchon. fl. 
Tr. digitalis 
Syrup, aurant. . 



Every four hours, for a child of five to 
eight years. 





gr. v 






TTI v 






HI V 






HI XX 




• q- 


s. ad 3 


iij 



Aquae 

Every four hours, for a child of five to 
seven years. 



Antimomi et potassn tartrat. . gr. f- - 
Liq. ammon. acet. . . ttt^ xx 

Syrup, tolu . . . . 1U xv 
Aquae . . . . q. s. ad 3 ij 
Every four hours, for a child of five 
years. 



MEASLES, p. 278 

Tr. aconiti . . . Tfl j 

Liq. ammon. citrat. (Br.) . TT], xx 
Elixir aromat. . . . tt[ x 
Aquae . . . q. s. ad 3 ij 

Every four hours, for a child of five 
years. 



Antipyrini . . . gr. iii-v 

Sp. chloroformi . TTI iij 

Elixir aromat. . . ttj, x 

Aquae . . q. s. ad 3 iij 

Every six hours, for a child of six 
years. 



INFLUENZA, p. 298 

Sodii salicylat. . . gr. v 

Liq. ammon. acet. . 3 ss 

Syrup, tolu . . 3 ss 

Aquae . . . q. s. ad 3 iij 



Every six hours, for a child of six to 
eight years. 



WHOOPING COUGH, p. 322 

(28) 



Tr. belladonnae 


. TIL V-XV 


Extr. cannabis ind. . 


• gr.i 


Glycerini . 


. Tn, xv 


Aquae 


q. s. ad 3 ij 



Every six hours, for a child of three to 
five years. 



Pot. bromidi 



gr- 



Liq. morphiae hyd. (Br.) . ill j 
Syrup, scillse . . . v\ xx 
Aq. aurant. flor. . ad 3 ij 

Every six hours, for a child of six to 

eight years. 



Antipyrini . . gr. iij 

Elixir aromat. . . tti^ x 

Aquae . . . q. s. ad 3 ij 

Every six hours, for a child of three to 
five years. 



Oubaine . . . . gr. -j-,, 1 ,,^ 

Sp. chloroformi . . \\\ j 

Aqua: . . . q. s. ad ' j 

Every six hours, for a child of 
six years. 



Bromoform. 

Two or three drops in a teaspoonful of water every four hours. 



8i8 



Diseases of Children 



PERICARDITIS, p. 344 



Pot. bicarb. 


• gr. x 


Sodii salicylat . 


. gr. x 


Tr. aconiti 


• TTl ij 


Liq. ammon. acet. 


3 ss 


Sp. chloroformi 


. Til V 


Syrup, aurant. . 


. 3ss 


Aq. aurant. flor. 


q. s. ad. § ss 


Aquae 


q. s. ad 3 ss 



Every six hours, for a child of eight to 
ten years. 



Every six hours, for a child of eight to 
ten years. 



CARDIAC TONICS, p. 346 



Tr. ferri chlor. 


. 


TTl V 


Ferri et ammon. citr. 


. gr. v 


Tr. digitalis 


. 


Til V 


Liq. strychnia? (Br.) 


• m ij 


Sp. chloroformi 




TTl V 


Sp. chloroformi 


. TTl V 


Aquae 


■ q- s 


ad § ss 


Glycerini . 
Aquae 


. TTl X v 

q. s. ad | ss 



Three times a day, for a child of eight to 
twelve years. 



Three times a day, for a child of eight to 
twelve years. 



DIURETICS IN CARDIAC DROPSY, p. 346 



Pot. acetatis 
Succi scoparii . 
Tr. digitalis 
Sp. chlor. 
Inf. senegae (Br.) 
Three times a day, for a child of eight to 
twelve years. 



. gr. x 


Pot. iodidi 


. gr. ij 


3 ss 


Tr. scillae 


• TTl V 


. TTl V 


Tr. strophanthi 


. m v 


. TTl v 


Sp. chlor. 


. TTL V 


. §ss 


Aquae 


q. s. ad f ss 



Three times a day, for a child of eight to 
eleven years. 





CARDIAC STIMULANTS, p. 346 




Sp. aetheris co. 


. TTl x Liq. strychniae (Br.) 


. m ij 


Tr. nucis vom. 


. TTl v Ex. cocae fl. 


. TTl xv 


Tr. lavandulae co. 


. TTl x Sp. chloroformi 


• TTl V 


Aq. carui (Br.) 


q. s. ad § ss Aq. cinnamomi 


. ad 5 ss 



Every four hours or as required, 

for a child of eight to twelve years. 

(Burney Yeo.) 



Every four hours, 

for a child of eight to twelve years. 

(Burney Yeo.) 



Sodii salicylat. 
Pot. bicarb. 
Syrup, aurant. . 
Aquae 



RHEUMATISM, p. 392 



gr. x 
gr. x 

3 ss 
s. ad 5 ss 



Potass, citratis . 
Syrup, limonis (Br.) 
Aquae 



. gr. x 

3 ss 
q. s. ad f ss 



Every four hours, for a child of ten years. Every four hours, for a child of ten years. 



Appendix 



EPILEPSY AND CONVULSIONS, pp. 501 and 506 

(29) 

Potass, bromid. 
Tr. belladonnas 
Sp. ammon. aromat. 
Syrup, aurant. . 
Aquae q 

Three times a day, for a child of eight 
years. 



. gr. vij 


Potass, bromid. 


. gr. v 


. TTl x 


Sodii bicarb. 


• gr- v 


TTl X 


Rhei 


• gr- \ 


3 ss 


Sp chloroformi 


TTL V 


. s. ad f ss 


Aquae 


q. s. ad § ss 



Three times a day, for a child of eight 
years. 



Sodii bromid. . . . gr. v 
Elixir cascara sagrad. . TTJ, x 

Sp. ammon. aromat. . TT[ v 

Aquae . . . q. s. ad § ss 
Three times a day, for a child of eight 
years. 

Potass, bromid. 
Chloral. . 
Syrup, aurant. . 
Aquae 



Potass, bromid. 
Syrup, aurant. . 
Sp. chloroformi 
Aquae 



• gr- "J 

• TTL j 

q. s. ad 3 j 



Potass, citratis . 
Syrupi limonis (Br.) 
Aquae . . . q. s. ad % ss 
Every four hours, for a child of six to 
ten years. 



. gr. iiss 


Chloral. . 


gr. iiss 


Nepenthe 


. TTL XV 


Elixir aromat. 


q. s. ad 3 j 


Aquae 


year old. 


For an in^ 


NEPHRITIS, pp. 559 and 561 




(30) 


. gr. xv 


Potass, tart. 


. m xx 


Syrup, aurant. 



Every two hours, for an infant of six 
months. 



gr. nss 
TTli 
TTl v 
s. ad 3 j 



fant of a year old. 



. gr. xv 

3 ss 

Aquae . . . q. s. ad § ss 
Every four hours, for a child of six to 
ten years. 



Liq. ammon. acet. 
Tr. digitalis 
Sp. chlorof. 
Aquae 



3 ss 

TTl v 

TTl v 

s. ad ^ ss 



Every four hours, for a child of six to 
ten years. 



Tr. ferri chlor. 
Acid. acet. dil. 
Liq. ammon. acet. 
Sp. chlorof. 
Aquae 



. TTl v 
. TTl ij 

3 ss 

. TTlv 

q. s. ad ^ ss 



Every four hours, for a child of six to 
ten years. 



Hydrag. chlor. mit. 
Euonymin 

Sacchari . 



ECZEMA, p. 732 

(3i) 
gr. \ Hydrag. c. cret, 



gr. t 
gr. j 



Pulv. rhei co. 

Sacchari . 



gr- ft 

gr.* 

gr- ) 



Evoy other night, for an infant of six months old. 



820 



Diseases of Children 



(32) 






(33) 




Ol. morrhuae 


!ij 


Ichthyol . 


. 


• ?ss 


Liq. potass, arsenit. . 


3j 


Carron oil 




. Oss 


Mucilaginis acaciae . 


q. s. 


To be applied on 


lint. 


Syrup, aurant. . 


Ij 








Aqua? . . q. s 


ad ^ iv 








One teaspoonful three times 


a day after 








food. 










(34) 






(35) 




Calaminae preparat. (Br.) 


3 ij 


Liq. plumb, subacetatis 


3 ss 


Zinci oxidi . . 


3 ss 


Tr. opii . 




• 3 ij 


01. oliv 


f J 


Aquae 


■ q- 


s. ad § vj 


Liq. calcis 


I J 


Ft. lotio. 






(Crocker.) 










(36) 






(37) 




Acid, boric. . 


3j 


Zinci oxidi . 




. gr. xx 


Ol. amygdalae express . 


3x 


Acid, carbolici 


. 


• gr. x 


Cerae alb. 


3 j 


Oleum rosae . 


. 


. m ss 


Cetacei 


3j 


Ung. lanolini 




• 1 ij 


Aq. rosae 


3x 


Ft. ung. 






Ft. ung. 










(38) 






(39) 




Acid, salicylatis . 


gr. x 


Sulphur precip. 




. gr. xx 


Zinci oxidi . 


3 ij 


Lanolini 




• 3 ij 


Amyli .... 


3 ij 


Vaselini 




• 3ij 


Vaselini 


|ss 


Zinci oxidi . 
Amyli . 




. 3 ij 
• 3 ij 


(40; 






(41) 




Ung. hydrarg. ox. flor. 


ij 


Ung. hydrarg. ox. rubri 


. §ss 


Five per cent. ess. vaselin 




Ung. zinci oxidi 
Cerati petrolii 




• oj 

• 3j 


(42) 






(43) 




Glyc. plumb, acet. 


3 ij 


Ung. picis liq. 




3 ss 


Liq. carbonis deterg. . 


3 ij 


Ung. hydrarg. ammon. 


• §ss 


Aq. rosae 


Ivj 


Ung. zinci oxidi 
Cerati petrolii 




• Si 

• Si 


(44) 






(45) 




Gelatine 


15 parts 


Gelatine 




15 parts 


Zinci oxidi . 


10 parts 


Zinci oxidi . 




10 parts 


Glycerini 


30 parts 


Adipis . 




10 parts 


Aquae .... 


40 parts 


Glycerini 




65 parts 


Add two per cent, of ichthyc 


il. 


Add two per cenl 


:. of salic 


ylic acid. 



Appendix 



821 



PSORIASIS, p. 74i 





(46) 






Ol. cadini . 
Ung. hydrarg. 
Ung. . 


ammon. 


3 ss 
• 3ij 


Chrysarobini 
Gutta-perchae 
Chloroformi 



(47) 



3j 
3j 

3x 



1^0 be applied to the affected parts. 
TINEA, pp. 742, 743. and 744 



(48) 




Sulphur precip. . 


• 3j 


Hydrarg. ammoniati . 


3 ss 


Thymol 


. gr. x 


Vaselini 


• 3j^ 


Ung 


ad 3 iv 


(5o) 




Tr. cantharides . 


• 3ij 


Tr. capsici . 


• 3ij 


Tr. nucis vomica? . 


1 ss 


Ol. ricini 


• 3ij 


Eau de Cologne . 


. ad §iv 



(49) 



Sod. borat . . . 3 j 

Spir. camph. . . 3 j 

Glycerini . . . 3 ij 

Aq. aurant. nor. . . q. s. ad § iv 

To be used as a hair -wash. 

(51) 
Tr. cantharid. . . . § ss 
Tr. capsici . . . § ss 

01. ricini . . . . § ss 

Alcohol . . . § iv 

To be used as a hair-wash. 



To be used as a hair -wash. 



(52) 



SCABIES, p. 746 



Sulphuris 


. 3j 


Styracis 




Balsam Peru 


3 ss 


Ung. . 




Ung. . . 


• . • !j 


(54) 






Naphthol 


. 


3j 




Ung. . 


. 


3 ij 



(53) 



5 iss 



INDEX. 



ABC 

ABCfes peribronchique, 219 
Abdomen, examination of, 77 
Abdominal abscess, 118 
Abdominal pain in spinal disease, 669 

— injuries, 749 

— section in intussusception, 132 

— wall, hiatus of, 146 
Abortive pneumonia, 228 
Abscess, acute glandular, 381 

— alveolar, 62, 607 

— cerebral, 467, 711 

— chronic, 386, 785 

— glandular, 381 

— hepatic, 180 

— iliac, 125 

— in bone, 590 et seq., 785 

— in hip disease, 646, 785 

— of the liver, 180 

— of the lung, 234 

— mediastinal, 248 

— periarticular, 644, 645 

— periesophageal. 73 

— periglandular, 382 

— periosteal, 590 

— perisigmoid, 121 

— peritoneal, 118 

— perityphlitis 117, 120, 125, 135 

— post-pharyngeal, 73 

— psoas, 650, 675 

— residual, 657 

— ■ retro-cesophageal, 73 

— spinal, 668-674, 785 
Absence of mouth, 169 

— of tongue, 167 
Accidental idiocy, 521 
A. C. E. mixture, 765 
Acetabular disease, 640, 647, 653 
Acetabulum, "travelling,'' 641 
Accidents with anaesthetics, 770 
Acquired clubfoot, 687 

— hernia, 147 

— syphilis, 427 

— talipes, 687 



AMP 

Acromioclavicular joint, disease of, 638 
Acute adenitis, 381, 383 
simple, 383 

— atrophic paralysis, 539 

— bronchitis, 210 

— tonsillitis, 65 

— cerebral paralysis, 473 

— circumscribed osteomyelitis, 602 

— epiphysitis, 602 

— gastro-intestinal catarrh, 80 

— generalised broncho-pneumonia, 125, 
219 

— glandular abscess, 383 

— hip-disease, 642, 788 

— meningitis, 440 

— miliary tuberculosis, 373 

— necrosis, 590 

— nephritis, 558 

— orchitis, 584 

— osteomyelitis, 591, 601 

— periostitis, 596 

— peritonitis, 113 

— rickets, 401, 778 

— simple serous synovitis, 619 

— suppurative arthritis of infants, 622 

— tubercular synovitis, 624 

— yellow atrophy of liver, 174 
Acutely inflamed tonsils, removal of, 71 
Addison's disease, 550 

Adenitis, acute. 379 

— tubercular, 379 
Adenoids, post-nasal, 72 
Adenomata recti, 155 
Adjacent abscess, 645 
Adolescence, rickets of, 414 
Age for operation in hare-lip, 160 
Air-passages, foreign bodies in, 205 
Albuminuria in diphtheria, 2S9 
Alimentary canal, 5 

Alopecia areata, 745 
Alum in whooping-cough, 322 
Alveolar abscess, 03. 607 
Amputation at hip-joint, 662 



824 



Diseases of Children 



AMP 

Amputation, intra-uterine, 695, 696 

— primary, 759 
Amussat's operation, 144 
Anaemia, 359, 786 

— idiopathic, 361 

— lymphatica, 366 

— pernicious, 361 

— splenic, 364 

— with oedema, 360 
Anaesthetics. 763 
Anal condylomata. 155 

— fissures, 155 

— fistula, 154 

Anastomosis, aneurism by, 356 
Anchyloglossus, 167 
Anchylosis of jaw, 637 
Aneurism, 358 

— by anastomosis, 356 

— of middle cerebral artery, 358 
Angina Ludovici, 386 
Angioma, cavernous, 350 

— lymphatic, 356, 716 

— simple, 350 

Angular curvature of spine, 664, 791 
Ankle, excision of, 633 

— tubercular diseases of, 618 
Anterior polio-myelitis, 538 
Antitoxin, 293, 771, 784 
Antipyretics. 778 

Anus, artificial, 144 

— imperforate, 142 

— ulceration of, 155 
Aortic regurgitation, 341 
Aphasia, 518 
Aphthous stomatitis, 59 

— vulvitis, 579, 778 
Apoplexia neonatorum, 18 
Appendicular peritonitis, 117, 120. 125, 

135 
Appendix, removal of, 121 
Arm, fractures of, 751 et seq. 
Arrest of growth after epiphysitis, 596 

in rickets, 407, 410, 413 

after injury, 753 ,754, 756 

Arterial nsevus, 349 

Arterio-venous varix, 355, 356 

Arteritis, 31, 484 

Arthrectomy, 627 et seq. 

Arthritis of infants, acute suppurative, 

622 

— rheumatic, 620 
Arthrodesis, 687 

Artificial muscle, 683, 690, 692, 793 
Ascaris, no 
Ascites, in 

— in cirrhosis, 178 



BOR 

Asphyxia neonatorum, 15 
Aspiration for empyema, 241 
Asthma, 245 
Asymmetry, 795 
Athetosis, 477, 493 
Athrepsia, 98 

Atlanto-axial disease, 676, 791 
Atresia ani, 142 

— oris, 160 

Atrophy of face, 169, 693 

— of brain, 458 

— gastro-intestinal, 98 

— of jaw, 637 

— of liver, acute yellow, 174 

— simple, 98 
Auricle, disease of, 707 

— supernumerary, 169 
Auscultation, 183 
Auvard, couveuse of, 17 

Axis traction for hip-disease, 655, 790 



Backward children, 523 

Balanitis. 576 

Barley water, 48, 798 

Barwell's artificial muscle, 683, 690, 692 

Basal ganglia, tumours of, 465 

Belladonna in whooping-cough, 322 

Bichloride of methylene, 765 

Biedert's cream mixture, 47 

Bifid anus, 142 

— tongue, 167 

— uvula, 159 

Bile-ducts, congenital stricture of, 173 

— secretion of, 6 
Birth, circulation after, 4 

— diseases incident to, 15 

— marks. 349 

— palsy, 471 
Bladder, calculus of, 562 

— extroversion of, 570 

— inflammation of, 566 

— rugous, 566 

— tubercular disease of, 566 

— tumours of, 566 
Bleeders, 33, 367 
Bleeding, 761 

— after excision of tonsils, 71 
Blennorrhagia, 30 

Blood, amount in body, 4 

— of infant, 4 
Body weight, 9 
Bone grafting, 750 
Bones, diseases of, 5S9, 785 

— syphilitic disease of, 433 et seq. 
Boric acid in diphtheria, 293 



Index 



825 



BOW 

Bowels, chronic obstruction of, 134 

— congenital obstruction of, 140 

— tubercular ulceration of, 136 
Bow-leg, 407, 411, 780 
Brain, abscess of, 467, 711 

— atrophy of, 458 

— congestion of, 439 

— cyst of, 460, 478, 482 et seq. 

— development of, 7 

— fever, 444 

— hypertrophy of, 457 

— sarcoma of, 460 

— sclerosis of, 458 

— softening of, 482, 484 

— surgery of, 468, 502, 711 

— syphilis of, 435, 458, 484 

— tumours of, 460 

— weight of, 7 
Branchial cartilages, 169 

— dermoid cysts, 169, 171 

— fistulse, 169 

median, 170 

Bromide rash, 742 

Bronchial glands, adenoma of, 248 

— diseases of, 246, 785 
Bronchiectasis, 212 
Bronchitis, 210 

— acute, 210 

— chronic, 213 
Bronchocele, 726 
Broncho-pneumonia, 214 

— in measles, 276 

— acute generalized, 219 

— chronic, 217 

— ■ disseminated, 219 

— micro-organisms in, 220 

— from tuberculosis, 375 
Bruit de pot fele, 183 
Bryant's splint, 654, 660 
Burns and scalds, 760 
Bursa of Fleischmann, 168 
Bursse in club-foot, 688 
Bursitis, 694 



C/ECAL colotomy, 145 
. — hernia, 148 

Calcaneo-astragaloid disease, 635 
Calculus of kidney, 557 

— in tonsils, 71 

— urethral, 563, 569 

— vesicae, 562 
Callisen's operation, 144 
Calomel fumigation, 196 
Canal of 1 lis, 170 
Cancrum oris, 64 



CHO 

Capillary nsevus, 349 

Caput succedaneum, 21 

Carbolic acid in whooping-cough, 322 

Carcinoma of stomach, 108 

Cardiac dilatation, 343 

— — in nephritis, 268 

— syncope in diphtheria, 290 
Caries, 589 

— of spine, 664, 791 
Carpo-pedal contractions, 477 
Cartilages, branchial, 157, 169 
Cartilaginous tumours, 715, 723 
Caseation of bronchial glands, 246, 785 

— of lung, 217, 249 
Catarrh, acute gastric, 85 
gastro-intestinal, 86 

— of bronchial tubes, 210 

— chronic gastro-intestinal, 98 
Catarrhal jaundice, 174 

— laryngitis, 189 

— synovitis, 620 

— tonsillitis, acute, 65 
Caudal appendage, 531 
Cavernous angioma, 349, 716, 720 

— nasvus, 349 

Cellulitis, deep cervical, 386 
Cephalhematoma, 20 
Cephalhydrocele, 748 
Cerebellar abscess, 711 
Cerebellum, tumours of, 462 
Cerebral abscess, 466, 711 

— cyst, 460, 478, 482 

— haemorrhage, 470 

— lesions, surgical treatment of, 46S, 711 

— paralysis, acute, 473 

— pneumonia, 229 

— softening, 451, 4S4 

— tumour, 460 

— congestion, 439 
Cerebro-spinal meningitis. 447 
Cervical cellulitis, 65, 386 

— paraplegia, 670 
Chest, examination of, 182 

— form of, in infancy, 182, 779 

— injuries of, 749 
Chevne-Stokes respiration, 443 
Chilblains, 73S 
Child-crowing, 1S4 
Childhood, 2 

Chloroform, 764 
Chlorosis, 360 
Cholera infantum, 91 
Chorea, 4S5 

— insaniens, 402 

— paresis in. 487 

— peripheral neuritis. 4S7 



826 



Diseases of Children 



CHO 

Choroid, tubercles of, 374 
Chronic bronchitis, 213 

— broncho-pneumonia, 217 

— circumscribed osteomyelitis, 604 

— diarrhoea, 83, 100 

— diffuse osteomyelitis, 606 

— gastro-intestinal catarrh, 98 

— hydrocephalus, 454 

— intussusception, 133 

— laryngitis, 208 

— nephritis, 560 

— obstruction of bowels, 134 

— periostitis, 598 

— peritoneal effusion, 122 

— peritonitis, 121 

— rheumatic arthritis, 620 

— tonsillar hypertrophy, 69, 189 

— tonsillitis, 69 

— vomiting, 100 

Circulation, changes in, after birth, 4 

Circumcision, 575 

Cirrhosis of liver, 177 

Classification of bone inflammation, 597 

Clavicle, deficiency of, 702 

— fractures of, 757 
Clavus hystericus, 468 
Cleft of lower lip, 166 

— of palate, 158, 163 
Clothing of infants, 38 
Club-foot, 678, 792 
Club-hand, 697. 795 
Club-leg, 690 
Coccygeal dimple, 530 
Colic, 74 

Collapse of lung, 212 
Colotomy, inguinal, 144 

— lumbar, 144 

Coma in meningitis, 443 
Complications of chorea, 489 
Compound congenital tumours, 721 
Condensing osteomyelitis, 608 

— ostitis, 5S9 
Condyloma of tongue, 168 
Condylomata, 155, 432 
Congenital deficiency of muscles, 693 

— deformities of digestive tract, 157 
of oesophagus, 171 

— dislocation of hip, 701, 795 

— heart-disease, 326 

— hernia, 147 

— hydrocele, 586 

— hypertrophy of oesophageal glands, 
76 

— idiocy, 519 

— laryngeal stridor, 183 

— mucoid cyst of tonsil, 69 



DAC 

Congenital nsevus, 349 

— obstruction of bowels, 140 

— rickets, 400 

— sacral fistula, 530 

— sacral tumours, 722 

— stricture of bile-ducts, 173 
of oesophagus, 171 

— syphilis, 428 

— syphilitic periostitis, 433, 598 

— tuberculosis, 378 

— tumours, 722 

— urethral anus, 145 
Constipation, 83 
Constriction of limbs, 695 
Contraction of meatus urinarius, 574 
Convulsions. 502 

Cord, separation of, 29 

Cortical layer, tumours of, 466 

Coryza, syphilitic, 429, 433 

Costo-vertebral disease, 677 

Couveuse of Auvard, 17 

Coxalgia. 639 

Craniectomy, 525 

Craniotabes, 397 

Cream mixture, 46 

Creeping pneumonia, 229 

Cretinism, 531 

Croton chloral in whooping-cough, 322 

Croup, diphtheritic, 192 

— membranous, 192, 773 

— spasmodic. 188 
Croupous angina, 294 

— exudation on navel, 31 

— pneumonia. 225 
Cryptorcbism, 580 

Curvature of spine, angular, 664, 791 

lateral, 421, 781 

rickety, 409, 779 

— of tibia 411 et seq., 780 
Cutaneous naevus, 350 
Cyanosis, 326 

Cystic disease of testis, 585 

— growth of vulva, 579 

— lymphangioma, 351, 358, 716 

— tumours, 716 et seq. 
Cystitis, 566 

— tubercular, 566 

Cysts, dermoid, 155, 171, 532, 588, 717 
et seq. 

— of jaws, 725 

— serous. 716 

— sublingual, 167, 716 



Dactylitis, syphilitic, 611 
— tubercular, 609 



Index 



827 



DEA 

Deaf -mutism, 516 
Deafness, 708 

Deep cervical cellulitis, 386 
Deformities of oesophagus, 171 

— in rickets, 407, 779 

treatment of, 417, 780 

rickets, operations, 418 

— of umbilicus, 146 

Deformity from thumb-sucking, 169 
Degenerated nsevus, 351, 355, 357 
Degeneration, reaction of, 541 
Dental formulas, II 
Dentigerous cysts, 725 
Dentition, ailments of, 55 

— course of, 1 1 

— second, 58 
Depressed scars, 385 
Derbyshire neck, 726 
Dermatitis gangrenosa, 741 
Dermoid cysts, 155, 171, 532, 588, 717 

et seq. 

branchial, 169 

of rectum, 155 

Developmental idiocy, 521 
Deviation of nasal septum, 704 
Diabetes insipidus, 389 

— mellitus, 388 
Diaphragmatic hernia, 151 
Diarrhoea, 81 

— chronic, 100 

— dysenteric, 96 

— lienteric, 82 

— in measles, 276 

— summer, 86 

— zymotic, 86 

Diet of infants, 53, 54, 796, 797 

— tables for indigestion, 106 
Digestive system, diseases of, 55 
Digitalis in heart-disease, 346 
Dilator, tracheal, 200 
Dilatation of the ventricles, 343 
Diphtheria, 283 

— antitoxin, 784, 771 

— diagnosis of, 291 

— pathology of, 285 

— treatment of, 292 

— albuminuria of, 289 

— cardiac syncope in, 290 

— epidemics of, 284 

— infectious nature of, 284 

— laryngeal, 289 

— malignant, 288 

— mild, 288 

— pharyngeal, 286, 772 

— pneumonia in, 290 

— quarantine in, 294 



EAR 

Diphtheria, bacillus of, 285 

— nasal, 288 

— wound, 289 

— prognosis in, 292 

— rashes in, 288 

— pseudo, 294 
Diphtheritic croup, 192, 773 

— infection of navel, 31 

— paralysis, 290 

— sore throat, 294 

Direct tubercular infection, 137, 663 
Disease of bones, 589, 785 

— of calcaneo-astragaloid joint, 635 

— of hip joint, 659, 788 

— of metatarsus, 609, 636 

— of phalanges, 609, 636 

— of sacrum, 636, 676 

— of temporo-maxillary joint, 637 

— of testicle, 584 
Diseases of joints, 612, 785 

— of liver, 172 

— of nose, 703 

— of respiratory system, 182 

— of retroperitoneal glands, 371 
Dislocations, 656, 759 
Dislocation of elbow, 759 

— of hip, 759 

congenital, 701,795 

— of patella, 759 

— of shoulder, 759 

congenital, 701 

Displaced nasal septum, 704 
Disseminated broncho-pneumonia, 215 

— myelitis, 536 

Distribution of lymphatic glands, 380 
Diverticula of oesophagus, 74 
Diverticulum, Meckel's, 29, 146 
Double monsters, 696 

— hip disease, 663 

— hip splint for spinal caries, 673 

— urethra, 574 
Dressings, 762 

" Dry bellyache/' 669 
Duck-toes, 690 
Ductus arteriosus, 4 
obliteration of, 4 

— venosus, 4 

Dyspeptic diseases of infancy, 7S 
Dysenteric diarrhoea, 96 
Dysphagia in spinal disease, 669 



Ear, closure of meatus of. 707 

— diseases of, 707 

— foreign body in the, 707 
Early life, periods of, 1 



828 



Diseases of Children 



ECL 

Eclampsia, 502 

Ectopia vesicae, 570 

Eczema, 729 

Elbow, disease of, 616, 787 

Embolism, 480 

— in nephritis, 266 

— tubercular, 663 
Emphysema, 211 

— in tracheotomy, 201 

— vicarious, 219 
Empyema, 234 

— from necrosis of rib, 596 

— surgical treatment of, 241 
Encephalocele, 531 
Enchondroma, 715, 723 
Encysted hernia, 147 
Endocarditis, 336 
Enlarged spleen, 363, 367, 434 
Enteric fever, 298 

abdominal symptoms in, 301 

bronchitis and pneumonia in, 302 

contagious nature of, 298 

diagnosis of, 304 

epistaxis in, 302 

— — haemorrhage in, 302 
incubation of, 299 

membranous tonsillitis in, 304 

mortality of, 298 

— ■ — perforation of intestine in, 303 

peritonitis in, 303 

pyaemia in, 303 

rash in, 302 

relapses in, 302 

symptoms of, 299 

temperature of, 300 

treatment of, 305 

tuberculosis in, 304 

Enucleation of tonsil, 71 
Enuresis, 567 
Epidemic influenza, 295 
Epidemic tonsillitis, 67 
Epilepsy, 497 

— trephining for, 502 

— post-hemiplegic, 499 
Epiphyses, separation of, 751 

— dates of union of, 757 
Epiphysitis, 591, 602 et seq. 

— acute, 602 

— syphilitic, 434 
Epispadias, 572 
Epistaxis, 706 
Epithelioma of kidney, 553 
Erasion, 627 

— of ankle, 633 
Eruptions, drug, 742 
Erysipelas, 315, 592, 762 



FIS 

Erythema, 737 

— multiforme, 391, 739 

— nodosum, 391, 739 

— pernio, 738 

— scarlatiniforme, 738 
Estlander's operation, 244 
Ether, 766 

Examination of chest, 182 
Exanthematous periostitis, 598 

— synovitis, 264, 620 
Excision, 629 

— of ankle, 633 

— of hip, 657, 791 

— of knee, 629, 789 

— of tarsus, 634 
for club-foot, 686 

— of wrist, 787 
Excoriation of navel, 30 
Exostosis, 716 
Expectorants, 782 

Extension for hip-disease, 655, 788 
External meatus of ear, closure of, 707 
Extravasation of urine, 563, 749 
Extroversion of bladder, 570 
Eyes, syphilitic affection of, 435 



Face, atrophy of, 169, 693 

— hypertrophy of, 169 
Facial paralysis, 710 
Faecal fistula, 118, 145 
False croup, 188 

— hydrocephalus, 89, 450 

— spina bifida, 529 
Fasting girls, 510 
Fat diarrhoea, 82 

Fatty degeneration, acute, 28 

— liver, 17S 

— tumours, 719 
Favus, 745 

Feeble vitality in hare-lip cases, 159 
Feeding, artificial, 43, 796, 797 

— bottles, 52 

— of infants at the breast, 38 
Femoral hernia, 151 
Femur, fractures of, 755, 758 
Fettmilch, 773 

Fever, infantile intermittent, 304 

Feverishness as a symptom, 254 

Fevers, 254 

Fibrocellular tumour of tongue, 168 

Fibrous tumours, 716 

Fingers, contraction of, 699 

Fissures of the anus, 155 

— of mouth in syphilis, 430 et seq. 

— of sternum, 702 



Index 



829 



FIS 

Fistula, in ano, 154 

— branchial, 169 

— intestinal, 118 

— tracheal, 171 

— umbilical, 118 
Flat-foot, 689, 793 

— in genu valgum, 413 
Flatulence, 79 

Foetal pericarditis, 336 

— rickets, 400 
Fontanelles, closure of, 7 
Foramen ovale, patent, 327 

Forcible straightening of limbs, 419, 780 
Foreign bodies in the air-passages, 205 

ear, 707 

nose, 703 

oesophagus, 75 

Fracture after necrosis, 597 
Fractured base of skull, 749 
Fractures, green-stick, 750 

— of long bones, 749, 781 

— of pelvis, 749 

— of skull, 748, 749 

— ununited, 750. 785 
Friedrich's disease, 538 
Frontal lobe, tumours of, 466 
" Fungus of the navel," 29 
Funicular hernia, 147 



Gangrene of the lung, 233 

— of the navel, 31 
Gastric juice, 5 

— catarrh, 85 

— pneumonia, 224 
Gastro-intestinal atrophy, 98 

catarrh, acute, 80 

chronic, 98 

enteritis, 95 

haemorrhage, 28 

Gastrotomy, 75 

General purulent peritonitis, 114 

— surgical tuberculosis, 387 

— tuberculosis, 373 

Genital organs, haemorrhage from, 29 
Genito-urinary diseases, 550 

— organs, malformation of, 570 
Genu extrorsum, 411 

— recurvatum, 699, 700, 794 

— valgum, 410, 780 

degree of, to measure, 416 

from rickets, appearance of, 410, 

780 

— varum, 411 
Giant-foot, 357, 720 
Girdle-pain, 669 



HEA 

Gland fever, 255 

Glands of groin, enlargement of, 644, 
645, 651 

— lymphatic, distribution of, 380 

— retroperitoneal, disease of, 125, 371 

— bronchial, disease of, 246, 785 

— mesenteric, disease of, 136 
Glandular abscess, acute, 383, 385, 386 
Glottis, scald of, 205 

— spasm of the, 184 
Goitre, 726 
Gonorrhoea, 36 
Gonorrhceal rheumatism, 622 
" Graines jaunes," 219 

" Grand mal," 498 

Green-stick fractures, 400, 403, 405, 750 

Growing fever, 604 

Growth, arrest of, 410, 413, 414, 596, 

751, 754, 756, 795 
Gumma, scrofulous, 383 



H^EMARTHROSIS, 368 

Hematoma of sterno-mastoid, 23, 691 

— occipital, 23 
Hsematuria, 550 
Hemoglobinuria, 347, 550 

— intermittent, 347 
Haemophilia, 27. 367 
Haemorrhage, 761 

— cerebral, 470 

— gastro-intestinal, 28 

— genital organs, 29 

— medullary, 479 

— meningeal, 471 

— newly born, 18, 20 

— umbilical, 33 
Hemorrhagic diathesis, 27 
Haemorrhoids, 154 
Hallux flexus, 700 

— valgus, 700 
Hammer toe, 700 
Hare-lip, 157 

— cases, feeble vitality in, 159 

— median, 166 

— operations, age for, 160 
Headache, 512 

Head, cold in the, 703 

— injuries, 74S 

1 lead-banging, 509 

— nodding, 509 

— shaking, 509 

Hearing in the newly born, S 
Heart, diseases of, 325 

— dilatation of. 343 
Heart-disease, chronic. 339 



830 



Diseases of Children 



HEA 

Heart-disease, congenital, 326 

— treatment of, 344 
Hemichorea, 487, 493 
Hemiplegia, 473 et seq. 

— from aneurism, 318 

— causes of, 474 et seq. 

— infantile, 473 

— from meningitis, 443 
Hepatic abscess, 180 
Hepatitis, interstitial, 177 

— syphilitic. 177, 434 
Hepatomphalos, 146 
Hereditary ataxic paraplegia, 538 

— syphilis, 428 
Hermaphrodites, 573 
Hernia, acquired, 147 

— congenital, 147 

— cerebri, 470 

— diaphragmatic, 146 

— encysted, 147 

— femoral, 147 

— funicular, 147 

— infantile, 147 

— of caecum, 148 

— and undescended testis, 581 

— inguinal, 147 

— of the ovary, 148, 584 

— radical cure of, 151 

— rectal, 151 

— strangulated. 147 

— translucency of, 147 

— umbilical, 147 

Herpes zoster in spinal disease, 670 
Hiatus vesicas, 570 

— of abdominal wall, 146 
Hip-disease, 639, 788, 790 
acute, 642 

double, 663 

— dislocation of, 759 
congenital, 701, 795 

— reflex muscular spasm, 789 

— results, 790 
His, canal of, 170 
Hodgkin's disease, 366 
Hollow claw-foot, 680 

— club-foot, 680 
Horse-shoe kidney, 550 
Hydatids of the liver, 180 
Hydrencephalocele, 531 
Hydrocele, 150, 586 

— of the neck, 167, 357, 358, 716 
Hydrocephalic cry, 442 
Hydrocephalus, acute, 454 

— chronic, 454 
Hydrocephalus, false, 89, 450 

— and spina bifida, 530 



INF 

Hydronephrosis, 557 
Hygroma, 167, 357, 358, 716 
Hymen, imperforate, 578 
Hyperpyrexia in pneumonia, 230 
Hypertrophy of brain, 456 

— of face, 169 

— of labia, 578 

— of tonsils, 69 
Hypospadias, 573 
Hysteria, 510 
Hysterical chorea, 492 

— joints, 638 

— vomiting, 80 
Hysteroids fits, 499 



Icterus neonatorum, 25 
Idiocy, 524 

— cretinoid, 521 

— syphilitic, 524 
Idiopathic anaemia, 361 
Ileo-umbilical diverticulum, 30 
Ueo-colitis. acute, 96 

Iliac abscess, 125, 135 
Imitation in chorea, 486 
Imperforate anus, 142 

— hymen, 578 

— rectum, 142 

Impetiginous eczema, 734, 735 
Impetigo contagiosa, 736 
Implication of nerve in callus, 757 
Incontinence of urine, 567 
Indigestion, diet table in, 106 
Infancy, definition of, I 

— dyspeptic diseases of, 78 

— mortality in, 13 
Infant, weight of, 9 
Infantile cholera, 86 

— convulsions, 502 

— hernia, 147 

— intermittent fever, 256 

— leucorrhoea, 578, 778 

— osteomalacia, 400 

— paralysis, 539, 687 
and hip-disease, 650 

— scurvy, 401, 778 
Infants, diet of, 38 

— feeding of , 38, 796, 797 
Inflammatory diarrhoea, 86 

Inflation of intestine in intussusception, 

129 
Influenza epidemic, 295 

— bacillus of, 296 

— treatment of, 298 

— relapses in, 298 

— pneumonia in, 297 



Index 



831 



INF 

Influenza, scarlatinal rash in, 297 

— tonsillitis in, 297 

— vomiting in, 297 
Inguinal adenitis, 644, 645, 651 

— colotomy, 144 

— hernia, 147 

Injections in intussusception, 129 
Injuries of soft parts, 760 
Intermittent fever, infantile, 256 

— hemoglobinuria, 347, 550 
Interstitial hepatitis, 177 
Intestinal fistula, 118 

— " kinks," 114 

— obstruction, acute, 125 

— worms, 109 

Intestine, congenital obstruction of, 140 
Intra-uterine amputation, 695, 697 

— life, 1 

— respiration, 3 
Intubation of larynx, 206, 773 
Intussusception, 125 

— abdominal section in, 132 

— chronic, 133 

Invagination of the bowel, 125 
" Inward fits," 504 
Irritable mamma, 580 

— rugous bladder, 566 



Jaundice, catarrhal, 174 

— of infants, 25 

— malignant, 173 

— in pneumonia, 230 
Jaw, anchylosis of, 637 

— cysts of, 725 

Joint disease, pyaemic, 620, 785 

— sense, 643 

Joints, diseases of the, 612, 785 
Jurymast, 672, 791 



Kidneys, congenital anomalies of, 550 

— diseases of, 550 
Kinks of intestine, 114 

Knee, diseases of, 613 et scq., 789 
Knock-knee, 410, 415 et scq., 780 

— from muscular spasm, 416 

— rickets, 410 
Kyphosis, 409, 426 



Labia, hypertrophy of, 57S 

— nsevus of, 5 78 

— ulceration of, 578, 579 
Labyrinth, affections of, 711 
Laminectomy, 676, 791 



LUN 

Landry's paralysis, 537 
Laryngeal diphtheria, 289, 773 
Laryngismus stridulus, 184, 397 
Laryngitis, catarrhal, 189 

— chronic, 208 

— spasmodic, 188 

Larynx, intubation of, 207, 773 

— papilloma of, 208 
Latent meningitis, 448 

Lateral curvature of spine, 244, 421, 781 

— treatment, 781 

from caries, 668, 791 

— meningocele, 528 
Late rickets, 414 

Leg, fractures of, 750 et seq., 785 

Length in infancy, 10 

Leontiasis ossea, 611 

Leucocythaemia, 367 

Leucorrhoea, infantile, 383, 578, 778 

Leukaemia, 367 

Lichen scrofulosus, 740 

— strophulus, 57, 741 

— urticatus, 740 
Lienteric diarrhoea, 82 
Life, intrauterine, 1 
Limbs, injuries of, 749 

— malformation of, 678, 795 

— rickety deformities of, 407 et seq., 779 
Lip, cleft of lower, 166 

Lipoma, 719 
Lipomatous naevus, 356 
Lithaemia, 552 
Lithotomy, 563 
Lithotrity, 563 
Little's tin splint, 683 
Littre's operation, 144 
Liver, abscess of, 180 

— acute yellow atrophy of, 174 

— cirrhosis of, 177 

— diseases of, 172 

— enlargements of, 172 

— examination of, 172 

— fatty, 178 

— hydatids of, 180 

— lymphadenoma of, 1S0 

— size of, 172 

— syphilitic affections of, 177 

— tuberculosis of, 179 

— tumours of, 1S0 
Lobar pneumonia, 225 
Lobelia in whooping-cough, 322 
Local anaesthesia, 764 

Loss of blood, 70 1 
Ludwig's angina. 386 
Lumbar colotomy, 144 
Lungs, abscess oi. 234 



832 



Diseases of Chi Id?' en 



LUX 

Lungs, caseation of the, 246 

— chronic tuberculosis of, 24S 

— collapse of, 219 

— gangrene of, 233 

— syphilitic affections of, 429, 433 

— vital capacity of. at different ages. 4 
Lupus, 3S3, 746 

— hypertrophicus, 383 
Lymphadenoma, 729 

— of bronchial glands, 24S 

— of liver, 180 
Lymphangiomata, cavernous, 356, 716 

— cystic, 167, 357. 716 
Lymphangitis, reticular, 379 
Lymphatic anaemia, 366 

— glands, distribution of. 3S0 

— naevus. 356, 716 

— varix, 357 
Lymphoma, 724 
Lymphosarcoma.. 724 



Macewen's operation, 419, 781 
Macrochilia, 166 
Macroglossia, 167, 355. 357, 716 
Macrostoma. 166 
Maculae, pigmentary. 352 
Malarial fever, 323 

Malformation of genito-urinary organs, 
570 

— of limbs, 694 

— of nose. 705 
Malignant jaundice. 174 

— disease of stomach, 108 

— polypi of nose. 705 
Malnutrition. 9S 

Malunion of fractures. 759. 785 
Mamma, irritable, 5 So 
Maniacal chorea, 4SS 
Manipulation for club-foot, 684, 792 
Mastoid disease. 709 et seg. 
Masturbation, 577 
Maternal impressions, 15S 
Measles. 272 

— incubation of, 274 
- — laryngitis in, 276 

— eruption in, 275 

— mortality in. 273 

— treatment of. 277 

— broncho-pneumonia in. 276 

— glandular enlargement in, 276 

— diagnosis of. 277 

— morbid anatomy of. 277 

— micro-organisms in, 273 

— quarantine in, 278 

— tuberculosis in. 277 



MOR 

Meatus urinarius, contraction of, 574 
Meckel's diverticulum. 30, 146 
Meconium, 6 
Median branchial fistula, 170 

— hare-lip. 166 
Mediastinal abscess, 246, 248 
Mediastino-pericarditis, 346 
Medulla, tumours of, 465 
Medullary haemorrhage, 479 
Membrana tympani, rupture of, 70S 
Membranous croup, see Diphtheria 

— laryngitis. 192 
Meningeal haemorrhage, 471 

post partum. 471 

Meningitis, acute simple, 444 

— cerebro-spinal, 447 

— chronic. 453 

— latent, 448 

— in pneumonia, 230 

— purulent, 448 

— simple. 444 

— spinal. 533 

— subacute, 446 

— syphilitic. 445, 453, 458 

— tubercular, 440 

— vomiting in. 442 
Meningocele. 531 
Meningo-myelocele, 528 

Mental affections in childhood, 519 

— defect affecting speech, 51 S 

— strain, 441, 4S6 
Mesenteric disease, 134. 136 
Metatarso-phalangeal disease, 636 
Methods of operating for hare-lip, 160 
Microstoma, 167 

Middle cerebral arterv, thrombosis of, 
481 

— ear, diseases of, 70S 
Miliaria, 741 

Miliary tuberculosis, acute, 373 
Milk, condensed, 50 
— ■ composition of, 43 

— cow's, 43, 796 

— " modified, "' 796 

— Pasteurization of. 797 

— human, composition of, 45, 772 

— peptonised. 4S 

— tubercular infection from, 137 
Misplaced testes, 5S0 

Mitral regurgitation, 337, 341 

Mixed naevus, 249 

Mobile spasm, 477 

Moles, 747 

Monsters. 696, 717 et seq. 

Morbus coxae, 639 

Mortality after tracheotomy, 205 



Index 



«33 



MOR 

Mortality in infancy, 13 
Mother's mark, 349 
Mouth, absence of, 169 

— defects of, affecting speech, 160, 517 

— deformities of, 156 

— diseases of, 59 

— examination of, 55 

M ucoid cyst of tonsil, 69 
Mucous cyst of pharynx, 73 

— patches, 432 
Mumps, 322 

Muscle splint, 683 et seq. 
Muscles, deficiencies of, 693 
Muscular atrophy, 548 

— spasm, 789 
Myelitis, 536 
Myelocele, 527 et seq. 
Myocarditis, 343 
Myositis ossificans, 693 
Myotonie, 549 
Myxolipoma, 719 
Myxcedema, 521 



JNL-EVUS, 349 

— congenital, 349 

— of labia, 578 

— lipomatodes, 356 

— lymphatic, 356 

— of rectum, 154, 352 

— of tongue, 355 
Narcotics, 779 

Nasal adenoid vegetations, 72 
Nasal catarrh, 703 

— obstruction, 704 
Navel, diseases of, 29 
Navel-urachus fistula, 30 
Necrosis of jaw, 62, 606 

— of patella, 607 

— post-typhoid, 62 

— of rib — empyema, 596 

— of spinous process, 664, 675 
Nephritis, acute, 558 

— chronic, 560 

— in diphtheria, 289 

malarial fever, 324 

pneumonia, 230 

scarlet fever, 264 

— septic, 264 

— parenchymatous, 559 
Nervous system, 7 

— diseases of, 43S 
Neuritis, 545 
Neuroma, 714 
Night cry, 643 

— starting, 643 



OTI 

" Nine-day fits," 34 
Nitrous oxide gas, 764 
Nodules, rheumatic, 391, 491 
Noma pudendi, 579 
Nose, diseases of, 703 

— dry catarrh of, 705 

— malformation of, 705 
Nystagmus, 509 



Oatmeal water, 48 
Obliteration of bile-ducts, 173 
Obstetrical paralysis, 24 
Obstruction of bowels, acute, 125, 134 

chronic, 135 

congenital, 140 

Obturators, 165 
Obturator teats, 160 
Occipito-atlantoid disease, 664, 791 

— dislocation, 701 
GEdema of scrotum, 578 

— neonatorum, 36 

Oesophageal glands, hypertrophy of, 76 

— varix, 76 
Oesophagitis, 76 
OZsophagotomy, 76 
Oesophagus, structure of, 74 

— deformities of, 171 

— foreign bodies in, 75 
Oidium albicans, 60 
Omphalitis, 31 
Onychia, 746 

— maligna, 746 

Open division in club-foot, 686, 792 
Operations under anaesthetics, 763 
Ophthalmia, gonorrhceal, 36 
Optic atrophy, 461 et seq. 

— neuritis, 442, 461, 488 
Orbital naevus, 354 
Orchitis, 584 
Osteoclasis, 41S, 7S1 
Osteoma, 716 
Osteomalacia, infantile, 400 

— in rickets, 400 
Osteomyelitis, acute, 601 et seq. 
circumscribed, 602 

— chronic circumscribed, 604 
diffuse, 606 

— condensing, 008 

— pyamic, 609 

Osteophyte growths in rickets, 413 
Osteotomy, 410. 7S1 

— for flexed knee, 63 1 

— of ribs. 243 
Ostitis. 589 
Otitis externa. 707 



834 



Diseases of Children 



OTI 

Otitis, media, 410, 416, 445 et seq., 467, 
708 

— in measles, 276 

— scarlet fever, 263 

— feverishness in, 238 
Ovarian hernia, 580 

— tumours, 588 

Overgrowth of limbs from periostitis, 597 
Overlying, 506 
Oxyuris, 109 
Ozaena, 705 



Pachydermatocele, 357 
Packs in scarlet fever, 271 
Pain, 761 
Palate arch, shape of, 165 

— cleft of, 163 
Papilloma, 747 

— of branchial fissures, 171 

— of larynx, 208 

— of tongue, 168 
Papules, syphilitic, 429 
Paracentesis in pericardial effusion, 345 
Paralysis, acute atrophic, 539 

cerebral, 473 

— after diphtheria, 290 

— infantile, 539 

— obstetrical, 24 

— pseudo-hypertrophic, 545 
Paralytic chorea, 492 

— club-foot, 687 
Paraphimosis, 577 
Paraplegia, 534 

— ataxic, 538 

— spastic, 471 

— in spina bifida, 528 

— in spinal caries, 534, 670, 676, 792 
Parenchymatous nephritis, 559 
Parker's operation in club-foot, 685 
Parosteal abscess, 590 

Parotitis, 322 

Patella, dislocation of, 759 

in knock-knee, 416 

— necrosis of, 607 
Patent urachus, 30, 570 
Peliosis rheumatica, 371 
Pelvic abscess, 646 

— deformity in rickets, 409., 414 
Pemphigus, 741 

— syphilitic, 429 
Penis, absence of, 575 
Peri-articular abscess, 619, 647 
Pericarditis, 331 

— acute, 331 

— chronic, 338 



PNE 

Pericarditis, diagnosis of, 335 

— symptoms of, 332 

— in chorea, 490 

— in nephritis, 266 

— in rheumatism, 391 

— in scarlet fever, 264 
Periglandular abscess, 382, 384 
Perinephritic abscess, 554 
Pericesophageal abscess, 73, 75 
Periosteal abscess, 590 
Periostitis, 590 

— albuminosa, 601 

— chronic, 598 

— exanthematous, 590 

— syphilitic, 599 
Peripheral neuritis, 545 
Periphlebitis syphilitica, 165 
Perisigmoid abscess, 121, 125 
Peritoneal abscess, 118 

— effusion, chronic, 122 
Peritonitis, acute, 113 

— appendicular, 117 

— chronic, 121 

cicatrisation from, 123 

— in enteric fever, 303 

— in nephritis, 267 

— purulent, general, 118 

— tubercular, chronic, 121 
Perityphlitis, 117, 125, 135 
Perityphlitic abscess, 117, 125, 135 
Pernicious anaemia, 361 

Pes cavus, 678, 686, 688 
in genu valgum, 413, 414 

— gigas, 357, 720 

— planus, 689, 793 

— pronatus acquisitus, 689 
"Petit mal," 498 
Pharyngeal tonsil, 72 
Pharyngitis, 72 
Pharynx, abscess of, 73 

— mucous cyst of, 73 
Phimosis, 575 
Phlebitis, umbilical, 32 
Phlegmonous periostitis, 590 
Phthisis, acute, 251 

— fibroid, 251 
Pigeon-breast, 398 
Pigmentary maculae, 352 
Piles, 154 

Pinna, diseases of, 707 
Plaster of Paris jackets, 672 
Pleurisy, 234 

— in rheumatism, 391 ' 
Pleuro-pneumonia, 230 

— in rheumatism, 391 
Pneumonia, abortive, 228 



Index 



83. 



PNE 

Pneumonia, cerebral, 229 

— creeping, 229 

— croupous, 225 
pathology of, 231 

— gastric, 229 

— in nephritis, 267 

— relapsing, 229 

— secondary, 2t6 

— wandering, 229 
Polypi, nasal, 705 
Polypus recti, 155 

— umbilical, 29 
Polyuria, 389 

Pons, tumours of, 465 
Porencephalus, 458 
Poroplastic jackets, 674, 784 
Port-wine stain, 349 
Post-hemiplegic epilepsy, 499 
Post-nasal adenoids, 72 
Post-partum meningeal haemorrhage, 

472 
Post-pharyngeal abscess, 73 
Pott's disease, 664, 791 

paraplegia in, 534, 670, 676, 791 

Prevertebral abscess, 73, 674 
Pressure sores in club-foot, 685 
Primary amputations, 759 

— resections, 759 

— union after excision of hip, 659 
Prolapse of rectum. 151 

— of urethra, 574 
Prostate, enlarged, 574 
Pseudo-diphtheria, 294 
Pseudo-hypertrophic paralysis, 545 
Pseudo-paralysis, syphilitic, 434 
Psoas abscess, 668, 675 

Psoitis, 125 

Psoriasis, 740 

Psychical phenomena of infants, 9 

Pulpy disease of joints, 612 et seq. 

Pulse at birth, 5 

Pulsus paradoxus, 346 

Purgatives, 781 

Purpura, 309 

— hemorrhagica, 369 

— simplex, 369 
Purulent peritonitis, 118 
Pyaemia, 591 et seq., 609 

— osteomyelitis in, 609 

— in periostitis, 591 et seq., 596 
Pysemic joint-disease, 620 
Pyelitis, 552 



" Quiet strumous disease," 615 
Quinine in pneumonia, 232 



RIC 

Radical cure of hernia, 150 

Radius, subluxation of, 759 

Ranula, 168 

Rarefying ostitis, 589 

Raynaud's disease, 347 

Reaction of degeneration, 541 

Reclining board, 425 

Rectal abscess in sacral disease, 676 

— fistula, 154 

— hernia, 151 

— naevus. 155, 352 

— polypus, 155 

— prolapse, 151 

— stricture, 153 

— ulcers, 155 

Rectangular talipes equinus, 681, 792 

Rectum, imperforate, 142 

Recurved knee, 699, 794 

Red corpuscles at birth, 4 

" Redressement force " in rickets, 418 

Reflex vomiting, 80 

Relapse after excision of tonsils, 71 

Relapsed club-foot, 684, 689 

— necrosis, 597 

Removal of sequestra from spine, 675 

— of inflamed tonsils, 71 
Renal calculus, 557 

— new-growths, 552 

Resection of bone in periostitis, 593 
Resections, primary, 759 
Residual abscess, 657 
Respiration in newly born, 3 

— intra-uterine, 3 
Respiratory spasm, 183 

— system, diseases of, 182 
Retention of urine, 563, 569 
Reticular lymphangitis, 379 
Retro-cesophageal abscess, 73 
Retro-peritoneal glands, diseases of, 371 
Retro-pharyngeal abscess, 73 
Rheumatism, 390, 4S9 

Rheumatic arthritis, 620 

— nodules, 391 
Rhinitis fibrinosa, 288 
Rickets, 393 

— acute, 401 

— of adolescence. 414 

— in animals, 395 

— bone changes in, 397 

— causes of, 393 

— congenital, 400 

— deformities of, 407. 770 
treatment of, 417. 7S0 

— foetal, 400 

— genu valgum from. 410, 7S0 

— heredity in, 39 | 



8 3 6 



Diseases of Children 



RIC 

Rickets, scurvy in, 401 

— syphilis and, 395 

— visceral change in, 405 

— late, 414 

Rickety pelvis, 400, 409 

— spine, 409, 780 

Rigidity of joints, congenital, 699 

Ringworm, 742 

Rizzoli's operation, 145, 781 

Roseola, 738 

Rotato-curvature of spine, 421, 781 

Rotheln, 279 

Rubella, 279 

— complications of, 282 

— diagnosis of, 282 

— incubation in, 280 

— morbillosa, 280 

— quarantine in, 282 

— rash of, 280 

— scarlatinosa, 281 

— treatment of, 282 
Rugous bladder, 566 
Rupture, inguinal, 147 

— umbilical, 147 

— urethral, 749 



Sacculi in lower lip, 166 

Sacral tumours, congenital, 720, 721 

— dimple, 530 
Sacro-iliac disease, 636 
Saliva, secretion of, 5 

— composition of, 5 
Salivation in children, 437 
Sarcoma, 713 

— of kidney, 552 
Sayre's jacket, 672, 791 
" Scabbard trachea," 727 
Scabies, 745 

Scalds, 760 

— of glottis, 205 
Scapula, deficiency of, 702 
Scarification of glottis, 205 
Scarlet fever, 257 

complications of, 263 

diagnosis of, 267 

enlarged glands in, 263 

from the cow, 258 

incubation of, 258 

malignant, 261 

micrococci in, 268 

mild form of, 261 

morbid anatomy of, 268 

mortality of, 258 

nephritis in, 264 

otitis in, 263 



SPA 

Scarlet fever, pneumonia in, 264, 267 

prognosis in, 263 

pyaemia in, 264 

quarantine in, 272 

rheumatism in, 264 

septicaemia in, 262 

surgical, 762 

symptoms of, 259 

treatment of, 268 

Scars, depressed, 385 
School-made chorea, 486 
Sclerema neonatorum, 35 
Sclerosis of bone, 588, 608 

— of brain, 458 
Scoliosis, 244, 421, 781 
Scorbutus, 377, 778 
Scrofula, types of, 377 
Scrofuloderma, 383 
Scrofulous gumma, 383 

— neck, 382 
Scrotum, oedema of, 578 
Scurvy, 362 

— infantile, 401, 778 
Seborrhcea, 737 
Senn's operation, 133 
Separation of the cord, 29 

— of epiphyses, 751 
Septicaemia in scarlet fever, 262 
Septic diseases, 762 

— nephritis, 262 

Septum ventriculorum, open, 329 
Serous cysts, 358, 716 

— synovitis, 612, 619 
Serum therapy, 771 
Shock, 761 

Shoulder, dislocations of, 701, 759 

— growing out of, 423 

— tubercular disease of, 616, 787 
Sight in infants, 8 

Simple acute adenitis, 383, 386 

— angioma, 349 

— naevus, 350 

— psoitis, 125 
Sinus cervicalis, 170 

— umbilical, 118 
Siren foetus, 528 

Skin affections in syphilis, 429 

— diseases of, 729 
Skull, cubic capacity of, 7 

— fracture of, 748 
Sleep, 9 

Softening of brain, 451, 484 
Spasm of glottis, 184 
Spasmodic laryngitis, 188 

— torticollis, 692, 794 
Spastic paraplegia, 471 



Index 



837 



SPE 

Speech, anomalies of, 515 
Spina bifida, 527 

occulta, 527, 723 

Spinal abscess, 666, 674, 785 

— deformity, angular, 666 

— meningitis, 533 

— meningocele, 527 

— rigidity, 669 

— sequestra, removal of, 675 

— splints, 672, 791 

— supports, 426, 672, 784, 791 
Spine, examination of, 422 

— lateral curvature of, 244, 421, 781 
causes of, 422, 779 

— rickety, 421, 780 

— rotato-lateral curvature of, 421, 781 
— - weak, 423 

Spinous process, necrosis of, 664, 675 
Spleen, enlargement of, 363 

— syphilitic affection of, 434 
Splenic anaemia, 364 

— enlargement in malaria, 324 
Sporadic cretinism, 521 
Spurious talipes valgus, 689, 792 
Stammering, 518 
Staphyloraphy, 164 

Status epilepticus, 500 
Steam tent, 190 
Steatose, 95 

Stellate nsevus, 349, 352 
Stenosis of the aorta, 330 

— of mitral valves, 330 

— of pulmonary artery, 329 
Sterilisation, 49, 773, 797 
Sterno-clavicular joint, disease of, 638 
Sterno-mastoid, hematoma of, 23, 691 

— tumour, 23, 691 
Stimulants, 783 

Stomach, capacity of, in infancy, 5 

— of infancy, 5 

— carcinoma of, 108 

— dilatation of, 107 

— malformations of, 108 

— ulcer of, 108 
Stomatitis, 59 

— ulcerative, 62 

Stone in the bladder, 562 
Strangulated hernia, 149 
Stricture of oesophagus, 74 

— of rectum, 154 

— of urethra, 569, 574 
Strophulus, 57, 741 
Strumous dactylitis, 609 

— nodes, 383 

— periosteal nodes, 598 
Subcutaneous neevus, 350 



TJE 

Subjective symptoms of spinal disease, 

669 
Sublingual cysts, 167 
Subperiosteal abscess, 590 
Sudamina, 741 

Sudden death in nephritis, 266 
Supernumerary auricles, 169 

— digits, 696 

— testes, 583 

Suppuration of bronchial glands, 246 
Suprapubic lithotomy, 563 
Suprascapula, development of, 702 
Surgical scarlet fever, 762 

— treatment of empyema, 241 

— tuberculosis, 387 
Swallowing foreign bodies, 75 
Syndactylism, 698 
Syndesmotomy, 685 
Synovitis, acute tubercular, 624 

— catarrhal, 620 

— exanthematous, 620 

— serous, 619 

— suppurative, 619 

— syphilitic, 621 

— tubercular, 624 
Syphilis, 427 

— acquired, 427 

— arteritis, 484 

— brain affection in, 435 

— congenital, 428 

— cranio-tabes in, 435 

— eye affections in, 435 

— hepatitis in, 433 

— hereditary, 428 

— lung affections in, 433 

— malnutrition in, 430 
: — post-vaccinal, 427 

— skin affections in, 431 

— visceral lesions in, 433 
Syphilitic coryza, 429 

— dactylitis, 611 

— epiphysitis, 434, 600 

— hip-disease, 649, 650 

— idiocy, 524 

— meningitis, 446, 453 

— ostitis, 434 etseq. 

— pemphigus, 431 

— pseudo-paralysis, 434 

— spleen, 434 

— teeth, 435 

— telostitis, 434 

— testitis, 5S5 
Syringo-myelocele, 528 

T.#:nia mediocanellata, no 

— solium, no 



838 



Diseases of Children 



TAL 

Talipes, acquired, 687 

— calcaneus, 67S, 680, 681, 6S6 

— cavus. 6S0, 686 

— equino- varus, 678 et seq., 792 

— paralytic. 687, 793 

— valgus, 680, 6S6, 689, 793 

— varus, 678 et seq. 
Tape-worm, no 
Tarsectomy. 634 

— for club- foot, 686 
Taste in infants. 9 
Teeth, eruption of, 10 

— syphilitic, 435 
Telangiectasis, 349 
Temperature in health. 7 

— at birth. 7 
Tenosynovitis, 693 

Tenotomy for club-foot, 685 et seq., 792 
Tent, steam, for laryngitis, 190 
Testis, abnormalities of, 580 

— diseases of, 5S4 

— inflammation of. 584 

— syphilitic. 585 

— torsion of, 584 

— tubercle of, 585 

— tumours, 585 

— undescended, 580 
Tetanus nascentium, 34 
Tetany, 507 

Thigh, fractures of, 758 

Thomas' splints. 418, 656. 673, 75S, 791 

Thomsen's disease, 549 

Thorax in infancy. 182 

Thread-worms. 109 

Thrombosis of cerebral sinuses, 483 

Thrush, 60 

Thumb-sucking, deformity from, 169 

Thymus, 727 

Thyroid, diseases of, 726 

— duct cysts, 169. 170 
Thyro-glossal duct, 169, 170 
Thyrotomy, 206, 209 

Tibia, deformities of. 411 et seq. 
Toes, diseases of. 636 
Tongue, absence of. 167 

— condyloma of, 168 

— malformations of, 167 

— naevus of, 168, 355 

— papilloma of. 16S 

— swallowing, 167 

— tumours of, 16S 
Tongue-tie, 167 
Tonsil, enucleation of, 71 

— guillotine. 71 

— pharyngeal, 72 

Tonsils, removal of inflamed, 71 



TUB 

Tonsillar calculus, 71 

— hypertrophy, 69 
Tonsillitis, acute, 65 

— chronic. 69 
Torsion of testis, 584 
Torticollis. 23, 691, 794 
Trachea, ulceration of, 203, 208 

— aspirator. 200 
Tracheal dilator, 200 

— fistulae, 171 

— stenosis. 204 
Tracheotomy, 196, 768 

— tubes. 202 

Traction diverticula of gullet, 74 
Translucent hernia, 147 
Transpatellar excision, 629 
Transposition of aorta, 331 
Transverse myelitis, 536 
Traumatic stricture, 749 
Trephining skull, 469. 711 

— for epilepsy, 470 

— spine, 676 
Trismus neonatorum, 34 
Trochanter, diseases of, 650 
Trophic ulcers. 528 
Trusses, 150 

Tubercles of choroid, 374 
Tubercular abscess of kidney. 555 

— embolism. 379, 663 

— shoulder, 616, 757 

— wrist, 617, 7S7 

— adenitis. 379 

— cystitis. 566 

— dactylitis. 609 

— disease of ankle. 618 
of elbow. 616, 7S7 

— infection from milk. 137 

— meningitis, 440 

anatomy of. 451 

symptoms of, 441 

treatment of. 452 

— synovitis. 612 et seq. 

— acute. 624 

— peritonitis, chronic. 121 

— testis, 585 

— ulceration of bowel. 136 
Tuberculosis of adrenals, 550 

— acute miliary. 373 

— congenital, 378 

— general. 373 

surgical, 387, 785 

sub-acute, 375 

— of liver. 179 

— chronic, of lung, 248 

— diagnosis of, 250 

— primary infection, 785 



Index 



839 



TUB 

Tuberculosis, symptoms of, 249 

— treatment of, 252 

— broncho-pneumonia, form of, 375 

— and scrofula, 377 

— typhoid form of, 373 
Tuberculous ulcers, 383 
Tubes for tracheotomy, 202 
Tumour growth, 713 
Tumours of basal ganglia, 465 

— of bladder, 566 

— of brain, 460 

— of cerebellum, 462 

— cerebral, 460 
removal of, 468 

— congenital, 716 et seq. 

— of frontal lobe, 466 

— of kidneys, 552 

— of liver, 180 

— of ovary, 588 

— of pons, 465 

— of testis, 585 
Types of scrofula, 377 
Typhlo-peritonitis, 117, 120, 125 
Typhoid form of tuberculosis, 373 

— fever, 298 

— synovitis, 620 
Typhus, 307 

— diagnosis of, 309 

— mortality in, 308 

— rash in , 309 

— symptoms of, 308 

— treatment of, 310 



Ulceration of bone, tubercular, 589 

— of labia, 579 

— of navel, 31 

— of nose, 705 

— of trachea, 203, 208 
Ulcerative endocarditis, 336 

— stomatitis, 62 
Ulcers of the anus, 155 

— of the rectum, 155 

— tuberculous, 383 

— vulvar, 383, 579 
Umbilical arteritis, 32 

— fistula, 118 

— haemorrhage, 33 

— hernia, 147 

— phlebitis, 32 

— polypus, 29 

— sinus, 118 

Umbilicus, deformities of, 146 

— diseases of, 29 

— gangrene of, 31 

— ulceration of, 30 



VOM 

Undescended testes, 580 

Union of epiphyses, dates of, 757 

Ununited fractures, 750, 785 

from necrosis, 597 

Uraemia in scarlatinal nephritis, 266 
Urachus, patent, 30, 570 
Uranoplasty, 165 

— obliteration of, 574 

— prolapse of, 574 
Urethra, rupture of, 749 

— stricture of, 574 

Urinary meatus, tumour of, 575 

— organs, diseases of, 550 
Urine, composition of, 6 

— extravasation of, 569 

— incontinence of, 567 

— retention of, 569 
Urticaria, 738 

Uvula, enlargement of, 72 

— naevus of, 355 

— papilloma of, 72 



Vaccination, erythema after, 315 

— erysipelas after, 315 

— glandular enlargement after, 315 

— performance of, 313 

— rashes after, 315 
Vaccino-syphilis, 349 

Vaginal discharge, due to worms, 109 

— haemorrhage, 29 
Vaginitis, 578, 778 

Vapour baths, in nephritis, 272 
Varicella, 310 

— contagious nature of, 310 

— diagnosis of, 313 

— eruption in, 312 

— gangraenosa, 312 

— incubation of, 311 

— quarantine in, 313 

— treatment of, 313 
Varicocele, 5S8 
Varioloid, 316 

— diagnosis of, 317 

— treatment of, 317 

Varix, arterio-venous, 355, 356 
■ — lymphatic, 356, 716 

— of oesophagus, 76 
Veal-tea, 777 
Venous naevus, 349 
Ventral hernia, 146 
Vesical calculus, 562 
Vicarious emphysema, 219 
Visceral naevus, 352 
Vital capacity of lungs, 4 
Vomiting, chronic, 98 



840 



Diseases of Children 



VOM 

Vomiting in cerebral tumour, 461 

— in chloroform anaesthesia, 767 

— in gastric catarrh, 85 

— in hysteria, 511 

— in infants, 79 

— in meningitis, 442 

— in obstruction of the bowels, 127 

— in peritonitis, 114 

— in scarlet fever, 259 

— in whooping-cough, 319 
Vulvar anus, 142 

— ulcers, 579 
Vulvitis, 578, 778 



Wandering pneumonia, 229 
Warts of vulva, 579 
Water on the brain, 454 
Weak spine, 423 
Weaning, 41 
Web-fingers, 698 

— toes, 699 

Weight and height, 10 

— increase of, 9 

— table of, 10 
Wet nurses, 40 
Whey, 48 



ZYM 

" White lock-jaw," 35 
Whooping-cough, 317 

— broncho-pneumonia in, 319 

— contagiousness of, 317 

— convulsions in, 319 

— diagnosis of, 320 

— diarrhoea in, 319 

— emphysema in, 319 

— incubation of, 318 

— pathology of, 320 

— tuberculosis after, 320 

— treatment of, 321 
Winckel's disease, 28 
Word-deafness, 516 
Worms, intestinal, 109 

— round, no 

— tape, no 

— thread, 109 

Wound management, 762 
Wrist joint, disease of, 617, 787 
Wryneck, 23, 691, 794 

Youth, 2 



Zymotic diarrhoea, 
— diseases, 254 






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Vol. I. 


Part I. 


" I. 


" II. 


" II. 


" I. 


" II. 


" II. 


" III. 


" I. 


" III. 


" II. 


" III. 


" III. 


" III. 


" IV. 


Appendix 


.. Super 



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